Disability and Rehabilitation

ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: http://www.tandfonline.com/loi/idre20

Hip external rotator exercise contributes to

improving physical functions in the early stage
after total hip arthroplasty using an anterolateral
approach: a randomized controlled trial

Manabu Nankaku, Ryosuke Ikeguchi, Koji Goto, Kazutaka So, Yutaka Kuroda
& Shuichi Matsuda

To cite this article: Manabu Nankaku, Ryosuke Ikeguchi, Koji Goto, Kazutaka So,
Yutaka Kuroda & Shuichi Matsuda (2016): Hip external rotator exercise contributes to
improving physical functions in the early stage after total hip arthroplasty using an
anterolateral approach: a randomized controlled trial, Disability and Rehabilitation, DOI:
10.3109/09638288.2015.1129453

To link to this article: http://dx.doi.org/10.3109/09638288.2015.1129453

Published online: 10 Jan 2016.

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 DISABILITY AND REHABILITATION, 2016
http://dx.doi.org/10.3109/09638288.2015.1129453

RESEARCH PAPER

Hip external rotator exercise contributes to improving physical functions in the

early stage after total hip arthroplasty using an anterolateral approach: a
randomized controlled trial
Manabu Nankakua, Ryosuke Ikeguchia, Koji Gotob, Kazutaka Sob, Yutaka Kurodab and Shuichi Matsudab
a
Rehabilitation Unit, Kyoto University Hospital, Kyoto City, Japan; bDepartment of Orthopedic Surgery, Faculty of Medicine, Kyoto
University, Kyoto City, Japan

ABSTRACT ARTICLE HISTORY

Purpose The purpose of this study was to investigate the effects of an exercise program focusing Received 6 October 2014
on hip external rotator muscle on physical recovery in the early post-operative period of total hip Revised 26 November 2015
arthroplasty (THA). Methods Patients who underwent THA were randomized to an exercise group Accepted 4 December 2015
(n ¼ 14) or a control group (n ¼ 14). In exercise group, the hip external rotator exercise program Published online 4 January
Downloaded by [La Trobe University] at 14:02 31 January 2016

was performed 5 times per week for four weeks. Outcome measures were hip pain, hip range of 2016
motion, muscle strength of lower extremity and Timed Up and Go (TUG) test. Results Both the hip
KEYWORDS
abductor strength (effect size ¼ 0.60) and TUG test (effect size¼ 0.53) in the exercise group Abductor strength and
improved significantly after the intervention. Conclusions The results of the present study exercise; arthroplasty; hip
demonstrated that exercise program focusing on hip external rotator muscle was an effective
intervention, especially in improving both hip abductor strength and walking ability in the acute
post-THA stage.

ä IMPLICATION FOR REHABILITATION

 After THA, in order to safely progress patients back to their desired activity level, there is a need
to develop rehabilitation strategies to expedite and promote the recovery during the acute
postoperative period.
 Exercise program focusing on hip external rotator muscle may lead to significant improvement
of hip abductor muscle strength and gait ability in the acute post-THA stage.

Introduction
Total hip arthroplasty (THA) is one of the most common
successful surgeries to reduce pain and improve func-
tional mobility in patients with severe hip osteoarthritis,
and enables such patients to resume their normal daily
activities. Physical therapy after surgery is now con-
sidered a standard treatment and consists of transfer
training, muscle strengthening exercises and gait train-
ing in the acute post-THA stage.
Many studies have reported that the physical functions
after THA are significantly improved when compared with
the preoperative values.[1–6] The greatest change in
muscle strength and walking ability after THA is observed
within six months postoperatively,[5] with more gradual
improvements occurring for up to 1–2 years.[6] However,
some studies have reported that the functional deficits
including muscle atrophy, muscle weakness and gait
disturbance persists even for two years after THA.[7–9]
More effective training programs need to develop
because traditional exercise has failed to restore muscle
strength or walking ability after THA.
The posterior approach by preserving the external
rotator muscles enhances hip joint stability.[10]
Yamaguchi et al. [11] also described that the poster-
olateral reconstruction at surgery including the hip
external rotator muscles results in improvement of hip
abductor strength after THA. Therefore, the hip external
rotator muscles may be important for the recovery of
physical functions after THA. However, these are no
clinical trials that evaluated outcomes of a training
program focusing on hip external rotator muscle
following THA.
The purpose of the current study was to explore the
question: whether exercise program focusing on hip
external rotator muscle during acute stage after THA
would promote a clinical improvement in patients.

CONTACT Manabu Nankaku nankaku@kuhp.kyoto-u.ac.jp Rehabilitation Unit, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto
606-8507, Japan
ß 2016 Taylor & Francis
 2 M. NANKAKU ET AL.
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Figure 1. Flowchart of the participants through the study.

Methods rheumatoid arthritis and musculoskeletal disease other

Design
The study was designed as a randomized controlled
study. This study was designed to assess the outcome of
28 patients with primary THA who were randomly
assigned to a group performing hip external rotation
exercise in addition to the conventional rehabilitation
programs (Exercise group) or to a group that partici-
pated in conventional rehabilitation programs (Control
group). The trial profile of the present study is displayed
in Figure 1.
All procedures in this study were approved by the
ethics committee of Kyoto University Graduate School
and Faculty of Medicine. The subjects were informed
about the study procedures before testing and provided
written informed consent before participating.
Participants
Twenty-eight patients were scheduled for THA in the
Department of Orthopedic Surgery of the Kyoto
University Hospital. All patients underwent THA using
an anterolateral approach.
The inclusion criteria were primary THA due to
unilateral osteoarthritis of the hip, a follow-up of 4
weeks, and asymptomatic knee and hip on the unin-
volved side. The exclusion criteria were neuromuscular
disease, cardiovascular problems, revision THA,
than osteoarthritis for which they received their
prosthesis.
Intervention programs
Control group
Patients were permitted for full weight bearing on the
third postoperative day and underwent a 4-week con-
ventional rehabilitation program. The patients were
encouraged and trained to move from bilateral to
unilateral support, and the goal of physical therapy
was to achieve ambulation with a cane-assistive device
by 4 weeks from the date of surgery. The conventional
strength training program for all patients having
inpatient treatment in our hospital consisted of gluteal
muscle sets, bridging, heel slides, hip abduction in
supine with no resistance, knee extension in sitting
position with low resistance and weight-bearing exercise
including bilateral heel raises, half squat.
Exercise group
In addition to conventional rehabilitation program,
exercise program of hip external rotator was performed
and supervised by an experienced physical therapist. The
hip external rotator training was performed in three
different body positions; in the supine and side lying
positions with the hip and knee flexed and in the prone

Figure 2. Method of measuring hip abductor and knee extensor strength. Hip abductor strength: lever arm for the hip abductor
strength is distance between the position of the force sensor and the greater trochanter. Knee extensor strength: lever arm for the
knee extensor strength is distance between the position of the force sensor and the level of the tibial plateau.
Downloaded by [La Trobe University] at 14:02 31 January 2016
position with the hip in neutral abduction/adduction
and the knee flexed at 90 angles. The exercise group
was instructed to perform the exercise program 5 times
per week for four weeks. Each exercise was performed as
three sets of 8–12 repetitions, with time for rest
equivalent to that of one set. Patients underwent
active assistive or active training in the first two weeks,
followed by low resistance training using elastic band in
the next two weeks.
Outcome measure
Physical functions in patient were measured before
surgery and four weeks postoperatively.
Hip pain at rest or during ambulation on the surgical
side was evaluated using the score for hip pain
according to the Japanese Orthopaedic Association hip
score.[12] The passive hip flexion and abduction angle in
a supine position was measured by using a universal
goniometer.
The maximum voluntary lower limb muscle strength
(hip abductor, hip external rotator and knee extensor) on
the operative side was assessed. The hip abductor and
external rotator strength were measured using a hand-
held dynamometer (Nihon Medix Co., Ltd., Matsudo,
Japan) during isometric contraction for 3 s with manual
resistance. When testing the hip abductor strength, the
subjects rested in the supine position with the hip and
knee in neutral flexion/extension and the hip in neutral
abduction/adduction. The force sensor was placed 5 cm
above the lateral condyle of the femur, while the
contralateral pelvis and distal thigh were fixed manually.
The hip external rotator strength was tested in the prone
position with hip maintained in neutral abduction/
adduction and the knee at 90 angles. The force
sensor was placed 5 cm above lateral malleolus.
HIP EXTERNAL ROTATOR EXERCISE AFTER THA 3
The knee extensor strength was assessed using an
IsoForce GT-330 (OG Giken Co., Ltd., Okayama, Japan)
during isometric contraction for 3 s. The patient was in a
sitting position with the hip at 90 angles and the knees
at 60 angles, the force sensor was placed over the
anterior part of the lower leg 5 cm above the lateral
malleolus. The torque was calculated by multiplying the
measured force by the lever arm (distance between the
position of the force sensor and the greater trochanter
for the hip abductor strength; distance between the
position of the force sensor and the level of the tibial
plateau for the knee extensor strength) and expressed as
a percentage of the body weight (Nm/kg) (Figure 2). The
values of hip external rotator strength were normalized
to the body weight (N/kg).
The Timed Up and Go (TUG) test [13] was conducted
to assess the patient’s walking ability. The TUG test
measures the time in seconds that a patient requires to
stand up from an armless chair with a seat height of
45 cm, walk a distance of 3 m, turn, walk back to the
chair and sit down. The test was performed with the
patients wearing shoes and walking at their maximum
speed with no assistive devices.
Statistical analysis
For the muscle strength determination and TUG test, the
best score of two trials was used for analysis. The paired
t-test or Mann–Whitney U-test was used to examine the
differences in each parameters before surgery and 4
weeks postoperatively. The unpaired t-test, chi-square
test or Mann–Whitney U-test also were used to examine
the differences in two groups. Analyses were performed
using SPSS for Windows (version 17.0; SPSS Inc.,
Chicago, IL). A p values50.05 was considered statistically
significant.
 4 M. NANKAKU ET AL.

Results Table 1. Patients’ baseline characteristics.

Exercise Control
Twenty eight of the 38 screened patients agreed to group group
participate in this study, and 14 in the exercise group (n ¼14) (n ¼14) p values
and 14 in the control group completed the program Age (years) 60.5 ± 6.4 60.8 ± 7.5 0.915
Gender (male/female) 2/12 2/12 0.998
(Figure 1). Compliance with the training program was Height (m) 154.8 ± 5.5 153.7 ± 9.4 0.714
excellent (100%) and the participants completed all Weight (kg) 55.9 ± 6.4 52.2 ± 9.9 0.247
Body mass index (kg/m2) 23.3 ± 2.4 22.0 ± 2.9 0.196
training sessions. Hip pain 20.7 ± 6.2 20.0 ± 6.8 0.772
Baseline characteristics for the 28 participants are Hip flexion angle (degree) 76.4 ± 17.5 80.7 ± 17.4 0.521
Hip abduction angle (degree) 16.8 ± 8.0 18.2 ± 9.1 0.663
summarized in Table 1. All parameters in age, gender, Hip abductor strength (Nm/kg) 0.63 ± 0.15 0.60 ± 0.14 0.596
height, weight, body mass index and preoperative Knee extensor strength (Nm/kg) 1.50 ± 0.62 1.84 ± 0.40 0.105
physical functions were not significant between the Hip external rotator strength (N/kg) 1.05 ± 0.27 0.97 ± 0.35 0.533
Timed Up and Go test (s) 8.50 ± 1.67 8.25 ± 2.07 0.734
two groups.
Table 2 shows the outcome measurements at baseline
and post-intervention. Postoperative hip pain and hip
range of motion in the two groups significantly improve Table 2. Outcome measurements at baseline and post-
compared with preoperative value. Hip abductor intervention.
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strength in the exercise group increased significantly Outcome measurements Baseline Post-intervention p values
after the intervention (effect size ¼ 0.60). No change in Hip pain
Exercise group (n ¼14) 20.0 ± 6.8 36.1 ± 2.1 50.05
hip abductor strength was found in the control group. Control group (n ¼14) 20.0 ± 5.6 34.6 ± 2.4 50.05
In the exercise group, the difference in hip external Hip flexion angle (degree)
Exercise group (n ¼14) 76.4 ± 17.5 82.5 ± 11.6 50.05
rotator and knee extensor strength between baseline Control group (n ¼14) 80.7 ± 17.4 86.6 ± 10.7 50.05
and post-intervention was not significant. Hip external Hip abduction angle (degree)
Exercise group (n ¼14) 16.8 ± 8.0 23.2 ± 7.0 50.05
rotator and knee extensor strengths in control group Control group (n ¼14) 18.2 ± 9.1 22.4 ± 4.6 50.05
were significantly lower at 4 weeks after THA. Hip abductor strength (Nm/kg)
Exercise group (n ¼14) 0.63 ± 0.15 0.72 ± 0.12 50.05
TUG test in the exercise group test improve signifi- Control group (n ¼14) 0.60 ± 0.14 0.58 ± 0.14 0.789
cantly after the intervention (effect size¼ 0.53). Knee extensor strength (Nm/kg)
Exercise group (n ¼14) 1.50 ± 0.62 1.37 ± 0.59 0.119
No change in TUG test were found in the control group. Control group (n ¼14) 1.84 ± 0.40 1.31 ± 0.40 50.05
Hip external rotation strength (N/kg)
Exercise group (n ¼14) 1.05 ± 0.27 1.05 ± 0.25 0.973
Control group (n ¼14) 0.97 ± 0.35 0.78 ± 0.39 50.05
Discussion Timed up and go test (Sec)
Exercise group (n ¼14) 8.50 ± 1.67 7.62 ± 1.08 50.05
After THA, patients not only wanted to get back to their Control group (n ¼14) 8.25 ± 2.07 8.61 ± 1.46 0.352
daily living activities but also wished to return to a high
level of physical activity, as soon as possible. Our earlier
study revealed that the physical functions in the early rotator muscle improve significantly after the interven-
stage after THA was a contributing factor to mid-term tion for 4 weeks. These results suggest that hip external
ambulatory status such as walking or descending/ rotator exercise was effective in improving early recovery
ascending stairs.[14] Judd et al. [15] also suggested of both hip abductor strength and walking ability after
that rehabilitation in the first month may be most THA. To our knowledge, this is the first report to indicate
effective because functional performance was dimin- that training focusing on hip external rotator muscle in
ished at one month after surgery. In order to safely the early stage post-THA is an effective intervention.
progress patients back to their desired activity level, Weakness of hip abductor strength was worse 1
these is a need to develop interventions to expedite and month after THA compared with preoperative
promote the recovery during the acute postoperative values.[15] In the result of this study, the hip abductor
period. However, there is a lack of evidence concerning strength of the post-intervention was 14.3% higher than
which clinical intervention is the most effective in the that of the baseline in patients who performed an
early phase after THA. Accordingly, the purpose of this exercise program focusing on hip external rotator
clinical trial was to evaluate whether training program muscle. In addition, strength of the hip external rotation
during acute stage after THA would promote a clinical after intervention was equal to preoperative levels in the
improvement. exercise groups. Yamaguchi et al. [11] described that the
The most important finding of this study was that the approximation of the acetabulum to the femoral head
hip abductor strength and TUG test in patients who due to preserving of the hip external rotator muscle may
performed an exercise program focusing on hip external result in strengthening hip abductor muscle after THA.

Our data confirm Yamaguchi’s hypothesis that hip joint
stability by hip external rotator muscle leads to
strengthening the hip abductor muscle following THA.
Abnormal gait pattern is traditionally associated with
impaired function of the hip abductor muscle.[16–18]
Walking speed has been shown to moderately correlate
with weakness of hip abductor muscles.[19,20] The
present study revealed that strengthening hip abductor
muscles by performing hip external rotator exercise
result in improvement of walking ability in the early
stage after THA, supporting the importance of
strengthening the hip abductor muscles in order to
achieve good clinical outcomes following.
Strength in the knee extensors of the surgical lower
extremity deficits was seen primarily rather than in the
hip musculature.[15] Similarly, the result of the present
study indicated that knee extensor strength in control
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group was lower significantly at 4 weeks after THA.
Physical therapists should consider including quadri-
ceps-strengthening exercises when developing rehabili-
tation programs for patients after THA because
quadriceps muscle weakness may result in poor func-
tional mobility.
Evaluation of participant compliance to the protocol
interventions is important to interpreting the key results
of a trial. In this study, compliance with the training
program was 100% and the participants safely com-
pleted all training session because all interventions in
this study were supervised training.
The current study has three major limitations. First,
although this study revealed that the physical functions
in patients who performed an exercise program focusing
on hip external rotator muscle improve significantly after
the intervention for 4 weeks, the intervention period of
this study was shorter than that of many researches.
Second, patient who underwent THA using poster-
olateral approach were not considered in the present
study. In the great majority of posterior approach, the
short external rotators are cut and repaired and cannot
be worked during acute stage after THA. Third, short-
coming of the study is a lack of long-term follow-up. We
have to analyze the data obtained longitudinally from
patients with longer follow-up. Despite the limitations
mentioned above, the present study yields valuable
findings that will help us indicate an effective training
method for improving the physical functions during the
acute postoperative period after THA.
Conclusion
The result of this study suggested that hip external
rotator exercise contributes to improving physical func-
tions in the early stage after THA.
HIP EXTERNAL ROTATOR EXERCISE AFTER THA 5
Declaration of interest
The authors did not receive and will not receive any benefits or
funding from any commercial party related directly or indir-
ectly to the subjects of this article.
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