Hip replacements have long been associated with elderly populations who typically present with low functional baselines. However, that ageist stereotype is slowly breaking as increasing numbers of younger, more active individuals are undergoing hip arthroplasties (and other total joint replacements in general) to address debilitating conditions such as hip dysplasia, slipped capital femoral epiphysis (SCFE), and avascular necrosis. This changing demographic has also renewed post-operative expectations. Many of these younger patients anticipate a return to premorbid activity levels—participating in high-impact or high-intensity endeavors—and these ambitions must be considered in conjunction with their long-term functional outcomes. But several questions arise:

• Are return-to-sport activity goals realistic for total joint recipients?
• What possible ramifications can sporting activities effect on artificial joints?
• What factors influence desired outcomes?

There is limited evidence suggesting high-level activities are detrimental to total joint replacement integrity, although it is generally accepted that activity level has a positive correlation to joint wear. In the absence of controlled clinical trials or prospective/retrospective analyses, post-operative activity recommendations are based on health care provider experience and collective opinion. Impact—the broad stroke term representing the amount of loading, shear, and torsion forces placed on joint articulations—is the primary determinant; however, there is currently no standardized measure to categorize sporting activities by level of impact. Examples of “low impact” sports include swimming, golf, stationary biking, and walking. These activities are considered safe to pursue following a hip replacement due to their relatively gentle internal joint forces. “High impact” activities—such as weightlifting, skiing, jogging, and tennis—place rapid, repetitive, high-amplitude forces through the joint complex, which may expedite prosthetic degeneration over time. 

High Impact Activity: Risks

One of the main concerns with high impact activity is the prospect of premature mechanical degradation. Prosthetic componentry—namely polyethylene spacers and polymethyl methacrylate (bone cement)—naturally break down over time. As these mechanisms wear, their fragments can accumulate inside the joint space or saturate adjacent osseous tissues. This may lead to excessive bone resorption and ultimately cause aseptic loosening of the prosthesis. However, no studies have been able to indicate that postoperative individuals who participate in high impact activities experience higher rates of prosthetic loosening. 

Dislocation and fracture are two additional risks that come with high impact activity. Excessive torque and loading forces may cause disarticulation of the prosthetic components or break weakened periprosthetic bone. But, much like aseptic loosening, there is little credible evidence supporting that high impact sports increase the likelihood of dislocation or fracture. 

Two scientific articles have examined the effects of high impact activity with the long term outcomes of total hip replacements. Gschwend et al. (2000) conducted a matched-cohort study where fifty postoperative participants regularly skied while their corresponding group did not. The authors followed up with all participants ten years after their respective procedures. Predictably, the skier group exhibited greater rates of prosthetic wear; however, the less active group experienced a higher number of postoperative complications, specifically aseptic loosening. These findings demonstrate that high impact activity participation and wear are not good predictors of prosthetic loosening. 

Low Impact vs. High Impact Activity

Ollivier et al. (2012) performed a retrospective analysis of total hip patients who either participated in high impact sports or low-level activity. Similarly to previous studies, the high impact group experienced accelerated wear patterns. However, unlike Gschwend et al., the high activity cohort was three times more likely to undergo revision/resurfacing procedures within fifteen years post-op to address prosthetic loosening. Despite these increased rates of wear and corrective surgery, the high impact group demonstrated “significantly better self-reported scores for symptoms, ability to perform activities of daily living (ADLs), and sports activities,” which indicate a higher overall quality of life.

Clinical practice guidelines for total joint procedures clearly require substantial updates to address their increasingly active surgical populations and ever-evolving medical technologies. Obviously, more thorough research needs to be conducted before any changes can be implemented. Based on current evidence, resumption of high impact and sporting activities seems doable following a joint replacement; however, certain factors may affect desired outcomes. First and foremost, patients should consult their surgeon, primary care physician, or physical therapist prior to initiating return to sport activities. The integrity of the prosthesis is of utmost importance. These health care providers can monitor their patients for signs of joint damage—groin pain, abnormal bulging, feelings of instability—and track their progress through sport-specific rehabilitation. 

Before independently returning to sport, patients much satisfy several objective criteria by demonstrating: 

1. Sufficient joint range of motion for desired tasks.
2. Muscle strength that can withstand and compensate for external forces endured during specific movements.
3. Adequate neuromuscular control for balance and coordination.
4. Dynamic stability that ensures postural control during active movement.

Typically, patients who regularly participated in sporting activities prior to surgery will have an easier time achieving these prerequisite functions. 

If you are an active individual considering a total joint replacement or have already received one, talk to your doctor about the effects high impact activity may have on your prosthesis.

Meet the Author

Dr. Timothy Murphy is a licensed Physical Therapist currently practicing outpatient therapy in the state of Virginia. He received his Bachelor of Science in Kinesiology and History in 2017 from the College of William and Mary, and Doctor of Physical Therapy (DPT) degree in 2021 from Old Dominion University. He is also an ACSM-Certified Personal Trainer, travel enthusiast, and lover of all things outdoors.

SOURCES

1. Bonnin, M. P. et al. (2018). Can patients practice strenuous sports after uncemented ceramic-on-ceramic total hip arthroplasty?. Orthopaedic Journal of Sports Medicine, 6(4), 2325967118763920.
2. Davis, C. (2018). TOTAL HIP REPLACEMENT POST-OP CLINICAL PRACTICE GUIDELINE. Retrieved February 4, 2022, from https://hrs.osu.edu/-/media/files/wexnermedical/patient-care/healthcare-services/sports-medicine/education/medical-professionals/hip/totalhipreplacement.pdf?la=en&hash=622323146BB495B688822D5126988FD59D669BA0 
3. Gschwend, N. et al. (2000). Alpine and cross-country skiing after total hip replacement: 2 cohorts of 50 patients each, one active, the other inactive in skiing, followed for 5-10 years. Acta Orthopaedica Scandinavica, 71(3), 243-249.
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