Chiropractic Management of Hip Pain After Conservative Hip Arthroplasty

Introduction 

Approximately 120,000 to 140,000 hip arthroplasties (HAs) with an additional 103,000 revision HAs and 30,000 partial hip replacements are performed annually in the United States. From 1982 to 1994, there was a 64% increase in HAs in the United States.1, 2 The most common reason for hip replacement is hip joint failure due to osteoarthritis, but other disease processes that lead to hip joint failure and subsequent joint replacement include rheumatoid arthritis, avascular necrosis, traumatic injury, bone tumors, and ankylosing spondylitis.2 The main purpose of HA is to decrease pain and to increase ability to perform activities of daily living.2 With an aging population and the increase of HAs being performed, chiropractors are likely to treat an increasing population of patients with HAs.

Research indicates that joint motion does not return to normal levels even 6 months after HA. These same studies indicate that patients with HA walk with a residual antalgic gait months after surgery.3, 4, 5 Research also indicates that patients who have had HA show shorter stride length, longer stance duration, and a slower gait than the able-bodied controls.6 This same study also indicated that the nonoperative hip and knee displayed the presence of some mechanical dysfunction, indicating possible future problems with the nonoperative extremity.6 Muscle weakness in the hip, particularly associated with hip abduction, is common in patients after HA.4, 7, 8, 9 Sicard-Rosenbaum et al8 found that, because of continuing muscle weakness after surgery and initial rehabilitation, HA patients note a detrimental impact on their lives because of pain and decreased mobility that continues beyond the initial rehabilitation program.

This article describes the case of a patient with persistent hip pain approximately 14 months postoperative HA. The patient was treated through chiropractic manipulative therapy (CMT) of the lumbar region by using flexion-distraction and the sacroiliac region by using posterior-anterior (PA) manipulation using pelvic and lumbar drop mechanisms. The patient was also given a progressive rehabilitation program to address both range of motion and muscular dysfunction. To my knowledge, this is the first article involving chiropractic treatment of a patient with hip pain after HA.

Case Report 

A 45-year-old man suffered from a 6-year history of bilateral hip pain that was originally diagnosed by an orthopedic surgeon as avascular necrosis. The patient subsequently underwent HA surgery of the right hip approximately 5 years before his visit to my office for treatment. The HA consisted of femoral head arthroplasty without changes to the acetabulum. The patient underwent extensive rehabilitation after right HA. The right hip had been asymptomatic since recovery from the initial surgery. The patient reported, with respect to the left hip, that a core decompression procedure was performed approximately 4 months before the right hip arthroplasty or about 5 years and 4 months before initial visit to this office. He reported that he had had a left hip arthroplasty approximately 14 months before the initial visit. He reported that the pain had decreased initially after HA surgery, but that the pain never went away and had gotten worse as time progressed. The patient underwent limited rehabilitation after HA on the left as compared with rehabilitation after the right HA. The patient did return to the surgeon approximately 7 months before the initial visit to this office and reported that he had been experiencing a “clicking” of the left hip. At that time, the surgeon prescribed muscle relaxation medication (Flexeril) and antiarthritis medication (Mobic) and limited the patient's activities. The patient reported that his condition had continued to worsen since that last visit. The patient also reported that radiographic studies had been performed by the surgeon at regular intervals, and he was informed that all was normal with respect to the bilateral HA. All accounts of history by the patient were verified through medical records obtained through the attending surgeon.

On the initial visit to my office, he described constant pain starting at or near the left anterior iliac spine radiating down the lateral leg and into the left knee on the lateral side. He also had a painful arthrogenic gait. Arthrogenic gait is also identified as a circumducted gait. With this gait, there is an arc movement of the affected limb, which helps to decrease the elevation needed to move the limb forward in the swing phase for a normal gait pattern. He also described “snapping” of the left hip with certain movements, specifically with both abduction and adduction of the left hip, and also described left lateral knee pain that increased in intensity as activity increased. The intensity of the pain limited not only work activities but also recreational and normal, everyday activities. He reported that he was unable to walk for extended periods and that he was unable to walk on uneven surfaces. He rated the pain in his left hip as being a 9 or 10 out of 10 on a visual analog scale.

On physical examination, the patient was found to have decreased visual ranges of motion of the left hip. He had normal reflexes bilaterally for both the L4 and S1 reflexes. Minor tenderness to palpation was noted in the left and right paravertebral musculature. Moderate tenderness was noted in the left gluteus medius and piriformis and trigger points were noted throughout the iliotibial tract. Muscle tightness was noted on both the left and right iliopsoas with contralateral hip and knee flexion while prone. Provocative tests (Noble Compression, Ober's) for iliotibial band contraction were also positive on the left side. During the examination, he was unable to stand on the affected leg because of both pain and lack of stability. Actual leg length was measured utilizing a flexible tape measure. The measurement was taken from the anterior superior iliac spine (ASIS) to both the medial and lateral malleoli. Measurement on the right was 79.0 cm to the medial malleolus and 80.5 cm to the lateral malleolus. Measurement on the left was 79.0 cm to the medial malleolus and 81.0 cm to the lateral malleolus. Measurements were necessary and used for parts of the Harris Hip Scale Evaluation.

Active ranges of motion were measured visually on the initial visit and then were measured by using goniometry on subsequent visits. The measurements were used as part of the Harris Hip Scale Evaluation, along with the previously mentioned leg length measurements. The patient also answered a series of questions pertaining to pain and function. Numeric values are attached to the answers and a score is then produced from 0 to 100, with 100 being the best score. The active ranges of motion and subsequent Harris Hip Scale Evaluation were performed regularly throughout the treatment period (refer to Table 1 for results).

Table 1. Ranges of motion of the left hip and Harris Hip Scale Evaluation scores on the corresponding visits throughout treatment

		Visit 1 (Day 1)	Visit 9 (Day 21)	Visit 13 (Day 42)	Visit 15 (Day 70)	Visit 17 (Day 98)	Visit 19 (Day 126)	Normal active ranges of motion30
	Flexion	25	85	85	90	90	100	110-120
	Extension	10	15	25	30	25	15	10-15
	Abduction	20	20	30	40	45	30	30-50
	Adduction	5	20	40	40	40	45	30
	Internal rotation	30	40	50	50	45	45	40-60
	External rotation	15	20	20	30	30	35	30-40
	Harris Hip Scale Evaluation score	35.85	61.575	63.575	69.725	85.725	95.875

Ranges of motion are used as part of the Harris Hip Scale Evaluation. The normal values for active hip ranges of motion are included for use as a comparison.30

Radiographic studies were performed of the lumbar region by using anterior-posterior (AP) and lateral studies. The patient was found to have the above-mentioned bilateral femoral head replacements. The patient was found to also have moderate degenerative disk disease at the L4-5 and L5-S1 levels. There was also degenerative joint disease in the posterior joints throughout the lumbar spine, with the spine being hypolordotic. There was no evidence of any gross malformations.

Treatment of the patient started with use of electric muscle stimulation and heat applied to the low back and pelvic region for 15 minutes. The patient was then treated with flexion-distraction in the lumbar region. A PA manipulation by using pelvic and lumbar drop mechanisms was used with respect to the left sacroiliac joint. Cox10 does not list hip replacement as a contraindication to distraction adjusting if well tolerated by the patient. The chiropractic manipulation stayed constant throughout treatment of the patient. On each visit throughout treatment, the patient was evaluated for joint fixations and was manipulated accordingly in the lumbar and sacroiliac joints. As treatment progressed, all rehabilitation exercises were modified to become increasingly more difficult to get gains in strength, ranges of motion, proprioception, and flexibility for not only the left hip but also the right hip and low back.

On the third visit (5 days from initial treatment), the patient was started with a rehabilitation program that included stretching of the iliopsoas and hamstring muscles, range of motion exercises for the left hip, and strengthening of the left hip abductors and left hip adductors. For the range of motion exercises, the patient was instructed to perform 10 clockwise circles followed by 10 counterclockwise circles with his left knee flexed on top of a 65-cm dynamic ball while standing on his right leg. The patient was instructed to do 3 sets of these exercises. For the strengthening exercises, the patient was placed in a side-lying position with the left leg superior. The patient was then instructed to abduct the left hip as far as possible. The patient was instructed to do this for 3 sets of 10 repetitions each. The patient was then placed in a side-lying position on the edge of a treatment table with the left leg inferior. The patient was instructed to abduct and adduct the left hip as much as possible, doing this for 3 sets of 10 repetitions each. All exercises were to be performed twice daily at home. On the fourth visit (7 days postinitial), all electric muscle stimulation and heat were stopped and the patient proceeded with in-office and home rehabilitation exercises as previously described. On the seventh visit (14 days postinitial), proprioceptive training for the pelvis and low back was added using the same 65-cm dynamic ball. The patient was instructed to kneel with both knees on the dynamic ball and try to remain steady for a period of 60 seconds. This was repeated 3 times, and the same home instructions of twice a day were given. On the eighth visit (18 days postinitial), along with the rehabilitation exercises, the patient was instructed to start a stretching program for the tensor fascia lata. This program consisted of side-lying stretches with the involved side being placed superior and that side being stretched.

On the ninth visit (21 days postinitial), the patient was reevaluated with regard to ranges of motion and the patient was again asked to complete a Harris Hip Scale Evaluation (Table 1). The side-lying exercises became easy for the patient, therefore a replacement was needed to continue to challenge and strengthen the muscles. As a replacement for the side-lying strengthening exercises, the patient was given a large piece of Theraband tubing (The Hygenic Corp, Akron, OH) for resistive exercises of the hip musculature. The patient was instructed to work on both the right and left by putting the hip through flexion, extension, adduction, and abduction, while having the tube anchored to an immobile object and placed around the foot. Exercises were to be done with 3 sets of 10 repetitions for each motion and with both legs. The patient was instructed to continue with the home exercise program, as well as the new strengthening exercises, twice daily. On the 10th visit (24 days postinitial), the patient was instructed to change proprioceptive exercises from using both knees on a 65-cm dynamic ball to using only 1 knee at a time. These exercises were to be done on both sides for 60-second repetitions for 3 sets. The patient was also instructed to continue the home exercise program. There was no change in treatment on the 11th visit (28 days postinitial) other than a switch from the red Theraband to a more resistive blue Theraband. Although the next step up would be green Theraband, the green Theraband was not used in this case because of equipment limitations at the treatment office. Between visits 11 and 12, the patient contacted the office and reported that he had been having increased pain in the left hip. He was instructed to stop Theraband exercises with the right (noninvolved) leg. Exercises were stopped on the right side because of the relative weakness on the left. When the patient was performing the right-sided exercises, the left extremity including the left hip musculature was being used to stabilize the body in the standing position. Because of the increase in resistance (red to blue), the stabilization (left leg and hip) had to work harder through the exercises and this added stress and then increased pain in the left hip. On the 12th visit (35 days postinitial), the patient reported improvement in the left hip. There was no change in treatment on the 12th visit.

On the 13th visit (42 days postinitial), the patient was again asked to fill out a Harris Hip Scale Evaluation form and active ranges of motion were measured (Table 1). The patient was instructed to pay particular attention to not holding on to any stabilization while doing the 1-legged proprioceptive exercises on the 65-cm dynamic ball. The patient was instructed to continue with his home exercises. On visit 14 (56 days postinitial), all dynamic ball exercises were stopped and the patient was given additional stretches for the gluteus maximus, gluteus medius, rectus femoris, psoas, and the hip adductors. The patient was instructed to do stretches bilaterally using a contract-relax technique. The patient was also instructed to continue the stretches for the tensor fascia lata. The patient was given a wobble board to continue proprioceptive training in the lower extremities. The patient was also instructed to continue with the previously described Theratube exercises.

On the 15th visit (70 days postinitial), the patient was evaluated by using the Harris Hip Scale Evaluation and active range of motion exercises were measured again by using goniometry (Table 1). On the 15th visit, rehabilitation exercises were modified with respect to the Theratube exercises. The patient was instructed to stop previously described exercises. Exercises were performed using hip flexion with equal hip abduction, hip flexion with equal hip adduction, hip extension with equal hip abduction, and hip extension with equal hip adduction. These exercises were to be performed with 3 sets of 10 repetitions each.

On the 17th visit (98 days postinitial), the patient was again evaluated by using the Harris Hip Scale Evaluation and active ranges of motion were measured by using goniometry (Table 1). All Theraband exercises were stopped due to increases in strength gained in the previous 3 months, but the patient was instructed to continue with the stretches and use of the wobble board.

On the 19th visit (126 days postinitial), the patient was evaluated by using the Harris Hip Scale Evaluation and active ranges of motion of the left hip were measured using goniometry (Table 1). Rehabilitation exercises were performed again and patient was instructed that he should do the stretching exercises on a daily basis indefinitely.

Discussion 

Adult hip surgery largely consists of hip arthroplasty in the United States.11 The primary indication for hip replacement is severe pain and the limitation of daily living activities and decreased hip ranges of motion. The primary goal of the HA surgery is the relief of pain with a resultant increase in hip ranges of motion, but the increase in ranges of motion do not occur in all HA patients.2, 12, 13 The ranges of motion of the surgically repaired hip should be good but not normal, and motion should be substantial to perform normal activities such as walking, sitting, climbing stairs, and entering a car.2, 12, 13 Towheed and Hochlberg14 found that beneficial and dramatic improvement in health-related quality of life occurred after elective total hip arthroplasty, and this improvement most often occurred within the first 3 months after hip arthroplasty. In this case, the patient does not follow the typical patient described previously because his left hip was no more pain free nor did he have much in the way of improvement in his daily activities after 3 months. As of the patient's initial visit, he had been post-HA surgery for 14 months.

Early complications of HA include fracture of the femur, acetabulum, and/or pubic rami; nerve injury; dislocation of the femoral component; deep vein thrombosis and pulmonary embolism; and wound complications; whereas late complications include infection, heterotopic ossification, and loosening of the HA.12 There is also the complication of “failed hip replacement” that is the result of wear produced by the friction between the metal femoral components and the high-density polyethylene acetabulum.15 Because the problems with the left hip were approximately 14 months postsurgery, all early complications were ruled out. Of these late complications, the “failed hip” complication was less likely, because the hip arthroplasty was only about 14 months old, along with the fact that the HA was considered conservative because the acetabulum was not altered or affected. The 2 remaining complications, heterotopic ossification and loosening of the HA, were also ruled out through physical examination and the examination by the surgeon, the surgical notes, follow-up examinations, and radiologic studies.

Sicard-Rosenbaum et al8 found that many patients continue to have significant postoperative lower extremity muscle weakness with an associated detrimental impact on their lives from pain and decreased mobility levels beyond the initial rehabilitation. In the Sicard-Rosenbaum et al8 study, all surgery patients were matched with a control subject that was similar in age and sex. The surgery group was at least 9 months postsurgery but no more than 72 months.8 As compared with the control group, the surgical patients were not able to walk as fast and had lower extremity muscle weakness with the associated hip.8 Hip abductor and flexor strength was found to be weaker on the nonsurgical side initially after surgery and at 1 year postsurgery.6, 7 Specifically, Vaz et al9 found that abductor strength of the surgically repaired hip was directly related to walking over a 6-minute period. Shih et al7 reported weakness in all of the muscles of the diseased hip of osteonecrotic men 1 year after hip arthroplasty as compared with the healthy hip. Whereas in another study, in which functional ability was assessed by measuring the levels of mobility and activities of daily living, it was found that 63.8% of HA patients still walked with some degree of a limp 24 months after HA surgery. Of these patients, 12.2% either walked with a bad limp or could not manage to walk at all. In this same group of patients, 20.4% still had poor physical ability 24 months postoperatively.16

It is well documented that gait is altered after HA. Gait is altered in speed of stride, length of stride, and difference in stance phase with respect to the surgical and nonsurgical hip.3, 4, 5, 6, 8, 9, 14, 17 McCroy et al3 found that HA patients favored their surgical leg by not putting as much force on it and not as quickly during walking. This same study also confirms that HA patients walk with a residual antalgic gait well after surgery but does not differentiate whether that is due to habitual movement pattern adopted prior to surgery or via biomechanical alterations from the HA.3 Furthermore, MacKinnon and Winter17 found that, in normal gait, upper body balance is controlled through hip adductors and hip abductors, and the movement of the L4-5 vertebral unit controls the coupling between the pelvis and the abdomen/thorax. This is accomplished through absorption of mechanical energy by the spinal lateral flexor musculature.17 Hip abductors play a large role in balance during gait.17, 18 The hip abductors must contract to prevent the pelvis from dropping on the contralateral side.18 In the case presented, gait was altered because of a combination of weak muscles, specifically abductors and flexors, and a lack of range of motion. The patient had difficulty with flexion and could not stand on the left leg due to pain and the inability of the abductors to maintain the stance because of the muscle weakness of the abductors of the left hip. The weakness of the left hip was so profound that the patient had difficulty not only with the initial rehabilitation of abducting the left hip against gravity but also with producing adequate force needed to stabilize his pelvis while standing on 1 leg or stabilizing his pelvis through the stance phase of gait.

The patient also presented with a “clicking” of the left hip during hip abduction and hip adduction on the left. Iliotibial band syndrome (ITBS) is believed to be caused by the iliotibial band sliding over the greater trochanter of the femur. ITBS is also a common cause of lateral knee pain.19, 20 The iliotibial band is part of the tensor fascia lata that continues on the lateral aspect of the thigh and attaches to the lateral tibial condyle. The iliotibial band also associates with the gluteus maximus via the tensor fascia lata.21 Some of the causes of ITBS include weakness of the knee flexors and extensors and weakness of the hip abductors.20, 22 The patient presented with signs of iliotibial band syndrome because of the “clicking” of the hip and the pain presentation. The patient presented with classic signs of ITBS that was treated through stretching of the iliotibial band and strengthening of the hip musculature.

The initial treatment for this patient was to address the fixations in the left sacroiliac joint along with fixations throughout the lumbar region. Research indicates that mobility of the pelvis and lumbar spine is directly related to gait.23 Robinson et al24 found that there was a distinct tendency toward improved gait with respect to symmetry after chiropractic treatment of chronic unilateral sacroiliac joint dysfunction. Wells et al25 studied the effects of osteopathic manipulation on the altered gait of Parkinson disease patients. The osteopathic manipulation consisted of manipulations to joints, including spinal and sacroiliac joints, along with muscle stretching techniques, including the muscles associated with both lumbar spinal and hip movement. All patients in the Wells et al25 study showed altered gait before treatment. After treatment, the researchers found significant positive differences between the experimental and control groups in stride length, cadence, and speed of ambulation. Researchers also noted differences from the control group in the relative velocities of the hip, knee, and ankle velocities.25 The chiropractic manipulation used in the present case was not the same as was used with Wells et al,25 but manipulation to the lumbar region and sacroiliac joint was done for the purpose of increasing mobility of these joints. Manipulation of the spine, specifically in the low back and pelvis, does have an effect on gait when that gait is deemed abnormal or altered. More specifically, fixations of the L4-5 vertebral unit can cause alterations in gait and it can be implied that correction of these fixations will improve gait.17

Although fixations of the spinal and sacroiliac joint were contributing to the pain and altered gait, the secondary problem with this patient was a severe weakness associated with the left hip and the lack of range of motion. Rehabilitative treatment at first dealt with increasing strength with respect to hip abduction and hip adduction to stabilize the pelvis through gait. Gross ranges of motion were also addressed with stretching and ball exercises. As treatment progressed, different stretches and strengthening exercises were added to address all ranges of motion in the hip. Muscle imbalances in the hip led to “altered movement patterns” as described by Fedoryk.26 Fedoryk26 describes hip extension dysfunction in which the gluteus maximus is the primary muscle responsible for extension and hip abduction dysfunction where the gluteus medius is the main mover of the lower extremity into abduction. The altered movement patterns via hip extension and/or abduction dysfunction will lead to pain in the lumbar region during prolonged walking, altered gait patterns throughout the lower extremity because of dysfunction of the main movers of the hip, pelvic drop, decreased ranges of motion in extension and abduction, muscle weakness, and sacroiliac joint dysfunction. Fedoryk26 reports treatment for both the hip extension and hip abduction is stretching of the primary movers (gluteus maximus and medius) and stretching of the antagonists (psoas, rectus femoris, hip adductors). The result is a relaxation and eventual strengthening of the weak, inhibited muscles.26

Stretches and strengthening exercises were added to address ITBS. Treatment for ITBS consists of stretching of the iliotibial band/tensor fascia lata along with strengthening of the hip abductors.20, 22 Fredericson et al22 found that improvement of symptoms associated with ITBS was directly related to the strength of the hip abductors. The study found that runners with weak hip abductors were generally those suffering from iliotibial band syndrome, and as strength increased in the hip abductors, the symptoms (pain) subsided.22 Both Fickel27 and DeFranca28 report correction of “snapping hip” syndrome with chiropractic manipulation of the sacroiliac joint. In both cases, tenderness was reported with both the gluteus maximus and medius.27, 28

Proprioceptive exercises were added to address approximately 6 years of dysfunction in the low back and pelvis. Proprioceptive exercises were eventually extended to the whole lower extremity to address altered gait and dysfunction throughout the lower extremity and low back. These exercises not only addressed proprioception of the low back and pelvis but also helped to increase the endurance of the hip musculature. Since the patient underwent bilateral hip arthroplasty, there was some degree of loss of proprioception in the hip joints, which theoretically placed more stress in the joints of the lower extremity, pelvis, and low back.

Although the patient presented with hip pain, the major problem was twofold: (1) articular fixations altered the biomechanics of the pelvis and lumbar spine, and (2) an altered gait pattern initially developed because of pain and then was worsened because of profound weakness of hip musculature following HA. In this case, the initial improvement may caused by to the CMT correcting fixations and thus biomechanics of the pelvis and low back. After months of rehabilitation to the left hip musculature and, to a lesser extent, the pelvis, low back, right hip, and bilateral lower extremities, a secondary improvement occurred at the end of the care. The need for rehabilitation became more apparent after treatment. The patient reported that there was little rehabilitation performed after the left HA compared with the rehabilitation performed after the right HA. The patient also reported no rehabilitation in the hospital postsurgery and few physical therapy visits with respect to the left HA. The lack of rehabilitation to the left hip may help to explain why the left side was symptomatic, whereas the right side was pain free. In this case, the patient did have bilateral HA approximately 5 years apart, with the right side being performed first and the left side being performed second. I believe that this profound weakness along with the previously discussed altered gait patterns3, 4, 5, 6, 8, 9, 14, 17 contributed to the pain in the left hip as opposed to the better rehabilitated right hip.

The improvements in this case are made from not only the clinician's observations and examinations but also through use of the Harris Hip Scale Evaluation. The Harris Hip Scale Evaluation is primarily a patient-answered survey addressing the pain in the hip and the ability to carry out gait and functional activities due to restriction of the hip. Part of the Harris Hip Scale Evaluation is an observation of deformity and range of motion of the hip being evaluated. Scores range from 0 to 100, with 100 being the best score.29 Using the Harris Hip Scale Evaluations, the patient initially scored 35.85 but increased to 61.575 after 8 visits. While a Harris Hip Scale Evaluation score of 61.575 is still considered poor, it is a vast improvement. In the first 8 visits, the main goal of treatment was to correct the fixations in the left sacroiliac joint along with any fixation present in the lumbar region. After the initial phase of treatment, rehabilitation of the left hip was stressed with the result being a steady improvement for the following 15 weeks of treatment when the patient had a Harris Hip Scale Evaluation score of 95.875. In this case, the Harris Hip Scale Evaluation was sufficient as a means to show improvement, but there were 2 flaws with its application, the first flaw with respect to the hip ranges of motion. On the initial visit, ranges of motion were visualized by the clinician and were meant to be approximate, whereas the subsequent ranges were performed with goniometry. The approximation in itself is inaccurate. In addition, goniometry is less accurate than using inclinometers or a computerized method to measure hip range of motion. The second flaw was that the patient completed the first Harris Hip Scale Evaluation on the sixth visit. The patient was instructed to complete the survey with respect to his condition before he entered the office for treatment. Because the survey was filled out retrospectively, there is inherent error. Overall, in this case, the Harris Hip Scale Evaluation was useful for documenting improvement other than asking the patient their level of pain and the clinician's observations.

Conclusion 

This case shows that chiropractic manipulation along with rehabilitation can be beneficial to patients with hip dysfunction. This case may also show that chiropractic manipulation may be beneficial to HA patients to help correct fixations in the lumbar and sacroiliac joints due to altered movement patterns that started before HA and continued after HA. It also shows the need to address not only the fixations present in the spine but also the severe muscle weaknesses and imbalances of the hip musculature. These muscle issues need to be addressed through rehabilitation to achieve maximum benefit for patients experiencing hip pain by improving low back and pelvic biomechanics caused by altered gait. Although no firm conclusions can be reached from 1 case, this case does indicate that ongoing hip pain after HA may be effectively treated through chiropractic manipulation to the lumbar and sacroiliac joints in association with rehabilitation of any dysfunctional muscles. This case also shows that, although a major factor with this patient was gross weakness of the left hip musculature, the chiropractic manipulation of the sacroiliac joint and lumbar region played a role in the treatment by addressing fixations that affected the gait of the patient.

Clinicians should be aware of patterns of altered gait and muscle weaknesses that are associated with HA patients3, 4, 5, 6, 7, 8, 9, 16, 17 to properly treat hip pain after HA surgery and also to detect abnormalities that may need to be addressed after HA with respect to gait and muscle imbalances. Because there is evidence that gait and muscle weakness still exist well after HA surgery, future research into the effects of chiropractic manipulation on the outcome of joint replacement patients is warranted.