Strategies for Return to Run after Total Joint Replacement

Dr. Jason Lunden // #FitnessAthleteFriday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Jason Lunden discusses the prevalence of runners returning after joint replacement, risks of returning to running, and how providers can set these athletes up for success on their return.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog

If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today.

JASON LUNDENHey, good morning, everyone. Welcome to another edition of the PT on ICE Daily Show. Happy Friday. My name is Jason Lunden. Uh, I am the lead for our endurance athlete division, and I am very excited today to talk to you about return to run following total joint replacement. So this is a topic that has held great interest to me for a number of years. Um, and really hasn't been a lot out there. Until more recently, there's still not a lot out there, but there have been some really neat studies that have come out in the past year that can help guide us with that. So today we're going to cover, one, do runners return to running following total joint replacement? Two, what are the risks that we and they need to be aware of? And then three, How can we set them up for success if they do indeed want to return to running?

DO RUNNERS RETURN TO RUNNING AFTER JOINT REPLACEMENT? So first, answering the question, do runners return to running following total joint replacement? The short answer is yes. I think we've all probably heard anecdotal stories of runners who've had a total joint replacement and returned to running despite being told that they should never return to running from their surgeon. Furthermore, a study from 2018 just looking at the prevalence of osteoarthritis in marathon runners made the observation that out of their cohort that they were studying, there were seven marathoners who were running with total joint replacement. So, you know, are these unicorns, you know, people who are going against the advice of their physicians and maybe their PTs and you know finding some success? Is it that they're finding very short-term success and then having to go on to you know early revision of their total joint? You know really didn't have any of that data until until recently. So a really cool study in 2023 came out by Antonelli et al looking at the return to run rate for runners following total joint replacement, namely total hip, unilateral knee, and total knee arthroplasty. And what they found is that yes, runners do indeed return to running following total joint replacement. And depending on the type of joint replacement they had, some of them return at a very high rate, while others return at a pretty modest rate. But overall, one of the interesting things out of that study is the number of people going into total joint replacement that classified themselves as a runner is actually really small when you're looking at the whole population out of the study. And that really, you know, reinforces our knowledge that we've been gaining recently that, you know, running is not a precursor to osteoarthritis and perhaps it may be chondroprotective. So that's one kind of neat takeaway from that study. The other really cool thing is that for patients following a total hip arthroplasty, if they're a runner prior to total hip, 75% of them returned to running after getting a total hip arthroplasty. With knee replacements, the percentage is much lower at around 10 to 15%. of those runners who were running, runners, and then going on to get a knee replacement, only 10 to 15% of them returned to running. And then even more surprising is a certain number of patients who did not run prior to joint replacement actually picked up running following joint replacement. About 1% of patients studied in the study. So yes, patients, can and do return to running following total joint replacement.

RISKS OF RETURNING TO RUNNING AFTER JOINT REPLACEMENT But what are the risks? I think we all have heard the narrative that you definitely should not avoid impact and avoid running following total joint replacement. And there are concerns for periprosthetic fracture, so fracture around where the orthodesis is or where the implant is. you know, concern for dislocation for total hip replacements, as well as polyethylene wear and loosening of the implant. Those are the kind of the four main concerns that surgeons have. And I think there, you know, is probably some validity to those concerns. And we do want to be thoughtful in having those discussions with patients if they are looking to return to run following total joint replacement. But another really neat finding out of the Antonelli study is that there was no difference in revision rates between those patients that went on to return to run following total joint arthroplasty and those that did not run at all. So the revision rate is around 5%, which depending on how you look at it, is either pretty small or still a pretty large number if we're thinking of 5% of people are having to go on to get a revision following the first total joint. And unfortunately, as with most surgeries, the second time around, the outcomes just aren't as good. So we definitely do want to avoid revision of a total joint if we can. And one way we can think about doing this is being really smart and methodical in how we're helping these patients return to running. Keep in mind that You know, following most lower extremity surgeries, patients actually see a decrease in bone mineral density, typically for the first year or maybe even up to two years following surgery. And that seems to peak in total joint patients at around three months, and then not actually improve, but the amount of loss peaks at about three months. So right around when we would be thinking about implementing a return to run program with a total joint patient, realize that their bone mineral density is probably at the lowest that it's been recently. And particularly if they are osteopenic patient or osteoporotic. You really want to go slow with them with implementing impact just to avoid periprosthetic fracture. So that also is making sure that you as a practitioner have knowledge of what's going on with the human in front of you, not just that they've had a total joint, but what's the bigger picture? Do they have a history of osteopenia or osteoporosis? And is there anything that they can do to help combat that?

SETTING PATIENTS UP FOR SUCCESS TO RETURN TO RUNNING So setting up our patients for success that do want to return to run following total joint replacement. One, we want to have a good idea of what's going on with them as a human and on a global scale and making sure that we're being specific to that. Two, regardless of that, we do want to have a slow progression with return to running and return to running volume. So this is a patient population where we definitely want to start with more of our walk, jog intervals than just going into straight jogging or running, making sure that they are able to tolerate a good walking program first. So being able to walk, you know, certainly 45 minutes or an hour without any issue, implementing impact in a controlled setting. So having them do stomping, um, you know, jump rope, uh, and, and things of that nature and making sure that they are tolerating some impact before we really get, uh, have them get to a lot of repetition, which running is a lot of repetition, um, for that. And part of doing that is really making sure that they are regaining and probably even gaining more strength than they had going into surgery, particularly with, if we're talking about the knee and the hip, quad strength, hamstring strength, and then global hip strength. So really making sure that they are, have had a good program with that and that they are at you know, 80 to 90% of what their contralateral leg is before even thinking about implementing a return to run program. And also making sure that what we're comparing their operative leg to with the contralateral leg isn't just comparing to, you know, crap numbers. So making sure that they do have a certain level of strength and fitness going into a return to run program. A couple things that we like to use as quick screening tools in the endurance athlete division are the ability to do single leg squats and the ability to be able to do at least 20 single leg squats with good form and with maintaining balance, as well as being able to do single leg heel raises and the ability to do at least, in this older population, 10 to 15 single leg heel raises to full height if possible. So we're really being methodical about how we're implementing that return to run program and progression of volume. We're making sure that prior to doing that, we have maximized their strength gains around the hip and the knee. And then we also want to make sure that they have the mobility to have, you know, the best gait mechanics that they can. So really making sure that they are getting, particularly with total hip patients, that they are getting hip extension, that they have good mobility of the rockers of the foot and ankle. So good ankle dorsiflexion, good, great toe extension, et cetera. And if they don't, working on that, either using your manual techniques or giving them some mobility drills to work on with that, And then bringing it all together with when we are implementing that return to run program, really trying to set them up for success by looking at their gait mechanics and then implementing some drills to help decrease impact at the hip and knee. Namely, if they do have decreased rockers, you know, and even with working on it manually and with some mobility drills, they're just not getting that back. getting them in a shoe with a rocker bottom to help with that can be extremely helpful in our older adult population. So something like, you know, Hoka has several shoes with a rocker bottom, as do other brands. And then if they're really limited in their, they're not able to get that hip extension or you're not observing hip extension at toe off, getting them to have a little bit of a forward lean, a forward lean not a forward bend so that they're basically just leaning their center of mass further forward to prevent over striding which over striding really increases impact at the hip and the knee and probably even more importantly it increases the the loading rate at the hip and the knee so those would be kind of two things to to really look for in your total joint patients that are returning to run. So in summary, you know, return to run for total joint replacements, yes, patients do and can, can and do return to run following total joint replacement. Much higher rate with, if they've had a total hip replacement compared to a total knee, but overall, those patients that we're working with that have had a total joint are likely to not be a runner to begin with. Two, we do want to be aware of what the risks are. There is no difference, at least in Tonelli's study, in revision rates between those patients that went on to return to run and those patients that did not return to run following total joint replacement, but those risks still are you know, I think valid with paraprosthetic fracture, risk of… hip dislocation, particularly if they were to fall, polyethylene wear, and implant loosening. So just really having a good understanding, particularly the bone health of the patient in front of you. And then lastly, set your patients up for success. Get them strong, work on their mobility, have all that tie into good gait mechanics, and slowly progress their volume. That's all I got for you today. Uh, thank you for listening.

SUMMARY If you are interested in treating endurance athletes, um, or you do treat endurance athletes and are looking for some CEUs, uh, we do have a variety of offer offerings within endurance athlete division. Uh, for coming up first is our second cohort of rehabilitation of the injured runner online, um, starting in early March. Also in March, we have our first offering. of the year of professional bike fit in Texas. And then we have a bike fitting offer, the professional bike fitting course offered also in April in North Carolina, and then in May in Minneapolis. And then our first rehabilitation of the injured runner live is going to be early June in Milwaukee. Come join us for those courses. We have a lot of fun and I think you pick up some really good skills and clinical pearls with treating endurance athletes. Have a great weekend, everyone. Get outside, do something fun with friends and family, and we will catch you later. Bye.

OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.