Total hip replacement is one of the most successful surgeries in modern medicine.

The
surgery helps to relieve hip pain associated with arthritis. The patients are able to get
back to their daily activities without the fear of pain. Some patients may however
complain of pain in the hip region after a total hip replacement. The pain may be
associated with the surgery or its complications or may be unrelated to the surgery.
The pain related to total hip replacement may be a result of bone loss, implant selection,
implant placement, residual cement, size of implant, nerve or muscle damage. However
in a number of cases, the pain may be unrelated to the hip replacement surgery and
may be referred to the hip area.

Pain after hip replacement surgery is evaluated extensively by the physician to diagnose
the cause of the pain. The physician performs a thorough physical examination which
may be followed by blood investigations and radiological studies such as an X-Ray, CT
scan or an MRI.
Hip pain with abnormal X-ray studies
 Loosening of the implant without any sign of infection is known as aseptic
loosening. The high grade polyethylene cup of the socket may release
microscopic debris following motion. The micromotion of the implant also
leads to debris accumulation.
Special cells in the blood known as macrophages, try to clear the debris but
in turn lead the body to attack the debris material with various enzymes and
proteins.
This in turn results in inflammation and loss of bone around the implant.
The loss of bone surrounding the implant may lead to loosening of the
implant.
The loosening is visible on an X-Ray as a clear space around the implant.
The implant may further sink in the femoral canal. Patients typically
complain of pain after a relative painless period after the surgery.
There are no signs of infection and the pain is worse on movement and
weight bearing. At times, patients may complain of rest pain as well.
 Septic loosening is the loosening of the implant secondary to the infection.
Infected hip replacement may lead to erosion of the bone around the
implant.
 The erosion and loss of bone is due to various chemicals released by the
infecting agent (usually a bacteria) and as a result of the body’s immune
system trying to fight the infection. There may be formation of tracts which
may open in the skin, leading to discharge of pus.
Patients may have a rise of temperature, swelling and redness of the hip
area. Some patients may have a low grade fever. The patient complains of
pain which is characteristically worse at night or rest. The pain may occur
immediately following the surgery or after weeks, months or years after the
surgery.
 Abnormal formation of bone in the tissues surrounding the implant such as
muscles is known as heterotrophic ossification. Heterotrophic ossification is
visible as bone tissue in the muscles surrounding the hip joint. Patients
complain of pain after a relative pain free period after the surgery. The pain
is worse with activity and gets better with rest.
 Thigh pain may occur as a result of stress shielding of the femoral stem. The
stiff femoral stem may impinge upon the weak bone especially further down
the thigh bone.
The stress of the femoral stem may lead to thickening of the bone down the
thigh bone. Stress shielding occurs due to mismatch of the forces acting at
the end of the femoral stem. Patients usually complain of thigh pain rather
than hip or groin pain.
 Osteolysis is the loss of bone surrounding the implant but without any
loosening. The loss of bone around the implant may lead to pain in the hip
region.
 Wrong sized implant and improper positioning of the implant may lead to
instability and reduced motion about the hip. The patients often complain
of hip pain which may be present in the groin, buttocks or the side of the
hip.

Hip pain with normal X-ray studies

 Iliopsoas tendinitis occurs due to the impingement of the iliopsoas tendon
as it crosses the hip joint in the front. Patients complain of hip pain in the
groin area and may walk with a limp secondary to pain.
The pain characteristically appears after initiation of walking. The iliopsoas
muscle helps in the bending of the hip. The pain therefore worsens on
bending (flexion) of the hip.
The impingement may occur as a result of malposition of the prosthetic
acetabular cup (socket). The impingement may also occur as a result of
retained cement particles during the surgery. A numbing injection in the
tendon may be used for diagnosing iliopsoas tendinitis.
 Reactive synovitis may cause hip pain after hip replacement. Synovitis may
occur as a result of osteolysis or may occur in the absence of osteolysis. The
reactive synovitis may be diagnosed with the help of an MRI.
 Damage to the muscle groups during the surgery may lead to postoperative
dysfunction and hip pain. The abductor muscles may be damaged during
the surgery and may lead to limping and associated pain.
 Bursitis of the trochanteric bursae may lead to characteric pain over the side
of the hip. The pain may be associated with pins and needles sensation. The
bursae are small sacs containing fluid that help the smooth passing of the
tendon and muscles over bony prominences.
 Improper position and uncovered prosthesis during the surgery may lead to
impingement of the prosthetic implant. The pain is worse with activity and
may get better with rest.
 Damage to the nerves surrounding the hip joint such as the sciatic nerve,
superior gluteal nerve, femoral and obturator nerve may lead to pain
following the surgery.
The risk of damage to a particular nerve depends upon the approach used
during the surgery and the technique of the surgery. The symptoms of
nerve damage may not be immediate in patients in whom a blood
collection in the area surrounding the nerve causes damage.
 Lumbar spine pathologies such as lumbar canal stenosis, prolapsed
intervertebral disc and facet joint disease, etc may cause radiating pain to
 the hip region. Through evaluation and history may help to differentiate the
radiating spine pain from hip pain.
 Rarely, pain may be referred to the hip region from a disease process in the
abdomen or due to inguinal hernia.

Are there specific exercises or rehabilitation techniques that can

target and alleviate pain after hip replacement surgery?
Yes, physical therapists can prescribe a variety of exercises and rehabilitation techniques
tailored to each patient’s needs and goals. These may include gentle stretching,
strengthening exercises, balance training, gait training, and functional activities to help
reduce pain and improve hip function.

Can certain lifestyle modifications help in managing pain after

hip replacement surgery?
Yes, adopting certain lifestyle modifications such as maintaining a healthy weight,
avoiding activities that put excessive stress on the hip joint, using assistive devices as
needed, practicing good posture, and following proper body mechanics can help in
managing pain and promoting long-term joint health after hip replacement surgery.

How important is it to adhere to post-operative instructions and

precautions to minimize pain and complications?
Adhering to post-operative instructions and precautions provided by the surgeon and
healthcare team is crucial for minimizing pain, preventing complications, and promoting
successful outcomes after hip replacement surgery. These instructions often include
activity restrictions, medication management, wound care, and follow-up appointments.

Is it normal to experience psychological distress or emotional

reactions such as anxiety or depression due to pain after hip
replacement surgery?
Yes, it is not uncommon for patients to experience psychological distress or emotional
reactions such as anxiety, depression, frustration, or fear due to pain or challenges
during the recovery process after hip replacement surgery. Seeking support from
healthcare professionals, family members, or mental health professionals can be helpful
in addressing these concerns.

How can I effectively communicate my pain levels and concerns

to my healthcare provider after hip replacement surgery?
Effective communication with your healthcare provider is essential for addressing pain
and concerns after hip replacement surgery. Keep a pain diary, be specific about your
symptoms, ask questions, express your preferences and goals for pain management,
and actively participate in shared decision-making regarding treatment options.

Are there any alternative or complementary therapies that may

help in managing pain after hip replacement surgery?
Yes, alternative or complementary therapies such as acupuncture, massage therapy, heat
or cold therapy, relaxation techniques, guided imagery, or dietary supplements may
provide additional relief from pain and support overall well-being after hip replacement
surgery. However, it’s essential to discuss these options with your healthcare provider
before trying them.

What are the potential long-term effects or complications of

persistent pain after hip replacement surgery?
Persistent pain after hip replacement surgery may impact a patient’s quality of life,
mobility, independence, and ability to perform daily activities. It may also increase the
risk of developing chronic pain, functional limitations, joint stiffness, muscle weakness,
or psychological issues over time. Early recognition and management of pain are crucial
for minimizing long-term effects and complications.

How does the type of hip replacement surgery (e.g., anterior vs.
posterior approach) impact post-operative pain and recovery?
The type of hip replacement surgery, such as anterior vs. posterior approach, can affect
post-operative pain, recovery time, and outcomes. The anterior approach may result in
less muscle damage and faster recovery, potentially leading to reduced post-operative
pain compared to the posterior approach. However, individual factors and surgical
techniques also play significant roles in determining pain levels and recovery outcomes.

How soon after hip replacement surgery can I start physical

therapy to address pain and regain mobility?
Physical therapy typically begins soon after hip replacement surgery, often within the
first few days or weeks, depending on the individual’s overall health status and the
surgeon’s recommendations.

What role does physical therapy play in managing pain after hip
replacement surgery?
Physical therapy is an essential component of rehabilitation after hip replacement
surgery, helping to improve strength, flexibility, and mobility while reducing pain and
promoting optimal recovery.
Are there any specific warning signs or symptoms that I should
watch out for regarding pain after hip replacement surgery?
Yes, warning signs or symptoms to watch out for regarding pain after hip replacement
surgery include sudden onset or worsening of pain, pain that does not improve with rest
or medication, swelling, warmth, redness, or drainage from the surgical site, fever, chills,
or difficulty moving the hip joint.

How can I differentiate between normal post-operative pain and

pain that may signal a complication?
Normal post-operative pain typically improves gradually over time and is manageable
with pain medications and other conservative measures. However, pain that is severe,
worsening, or accompanied by other concerning symptoms such as fever, redness,
swelling, or difficulty bearing weight may indicate a complication and requires medical
attention.

Should I be concerned if I experience persistent or severe pain

after hip replacement surgery?
Persistent or severe pain after hip replacement surgery may indicate underlying issues
such as infection, implant loosening, dislocation, nerve damage, or other complications,
and should be promptly evaluated by a healthcare provider.

How effective are non-drug therapies such as physical therapy or

acupuncture in alleviating post-operative pain?
Non-drug therapies such as physical therapy, acupuncture, or transcutaneous electrical
nerve stimulation (TENS) can be effective complementary approaches to pain
management after hip replacement surgery, helping to improve mobility, reduce
inflammation, and alleviate discomfort.

What medications are commonly prescribed to manage pain after

hip replacement surgery?
Pain management medications may include nonsteroidal anti-inflammatory drugs
(NSAIDs), acetaminophen, opioids, muscle relaxants, or nerve pain medications,
depending on the individual’s needs and tolerance.

Are there specific activities or movements that may exacerbate

pain after hip replacement surgery?
Yes, certain activities such as high-impact exercises, heavy lifting, or prolonged periods
of standing or walking may exacerbate pain during the recovery period after hip
replacement surgery.
How long does it typically take for the pain to subside after hip
replacement surgery?
The duration of pain after hip replacement surgery varies among individuals, but it often
improves gradually over several weeks to months as the surgical site heals and the body
adjusts to the new hip joint.

What are the most common causes of pain after hip replacement
surgery?
Pain after hip replacement surgery can result from various factors such as inflammation,
nerve irritation, muscle strain, implant-related issues, infection, or complications related
to the surgical procedure.

Cup inclination in the coronal plane have been reported to range between 35 and 50 degrees normally,
although Odri and colleagues reported 40-50 degrees as an optimal range. Their research demonstrated
that the acetabular cups of those with iliopsoas impingement following total hip arthroplasty had
significantly lower inclination compared to a painfree control group. The median angle of inclination was
at the lowest end of the normal range - 40° (range 20-56°) in those with iliopsoas impingement,
compared with 46° (range 20 - 75°) in those without pain5. Excessive cup downward inclination will
result in greater overhang of the cup relative to the native acetabulum and pressure against the
overlying iliopsoas.

pain results from a mechanical conflict between the iliopsoas tendon and the anterior edge of
the acetabular cup after total hip arthroplasty.

Pain can be reproduced by active flexion of the hip and by active raising of the straightened leg.
In addition, painful leg raising against resistance and passive hyperextension are suggestive of
an irritation of the iliopsoas tendon.

Symptoms evolve from a mechanical irritation of the iliopsoas tendon and an oversized or
retroverted acetabular cup, screws penetrating into the inner aspect of the ilium, or from bone
cement protruding beyond the anterior acetabular rim. The diagnosis may be assumed on
conventional radiographs and confirmed by CT scans.
ANTERIOR PELVIC TILT  THIGHT ILIOPSOAS AND NARROW SPACE IN ANTERIOR HIP?
The femoral nerve innervates the sartorius, pectineus,
quadriceps femoris, and iliacus muscle of the iliopsoas. It receives
nerve supply from the nerve roots L2-L4, innervating both the hip
flexor and quadriceps muscle groups. The femoral nerve is also
responsible for anterior thigh and medial leg sensation
What is Acetabuloplasty? An acetabuloplasty is a surgical procedure
employed for the correction of a condition known as pincer
impingement. Pincer impingement is a form of hip impingement, also
known as femoroacetabular impingement (FAI).
acetabuloplasties. : plastic surgery on the acetabulum intended to restore its normal state (as by
repairing or enlarging its cavity)

Pincer. This type of impingement occurs because extra bone extends out over the normal rim of
the acetabulum. The labrum can be crushed under the prominent rim of the acetabulum. Cam.
In cam impingement, the femoral head is not round and cannot rotate smoothly inside the
acetabulum.

more shock will be transmitted to the knee by a more severe fracture,

which ultimately results in greater knee pain

Hip fractures are classified as either intracapsular or extracapsular.

Intertrochanteric fractures are categorized as extracapsular, whereas
femur neck fractures are categorized as intracapsular fractures [25].
These results are consistent with our hypothesis and suggest that, when
hip fracture occurs, the joint capsule and synovial fluid appear to have a
shock-absorbing effect in reducing abnormal stress transmitted to the
knee.