Walking After A Total Hip Replacement and Femoral Nerve Palsy

After undergoing a total hip replacement and suffering from femoral nerve palsy, Mangiarelli Rehabilitation physical therapy patient Kay has made incredible progress, advancing from walking with a brace with a walker to now walking with a cane! Femoral nerve palsy post-hip replacement involves injury to or compression of the femoral nerve, one of the largest nerves in the leg that stimulates the quadriceps and hip flexor muscles and helps bend and straighten the leg, knees, and hips. Physical therapy after a total hip replacement and femoral nerve palsy is essential. A physical therapist can help reduce compression on the nerve and help patients safely and gradually regain quadriceps muscle strength, relieve nerve pain, and improve walking ability.

What is the Femoral Nerve?

The femoral nerve is one of the largest nerves in your leg that originates from the L2-L4 (low back) nerve roots in the lumbar plexus and enters the femoral triangle, a hollow, wedge-shaped area between the upper thigh and the groin. The femoral nerve stimulates the thigh (quadriceps) and hip flexor muscles to help bend and straighten the leg and bend your knees and hips. The femoral nerve also senses touch, pain, and temperature and transmits these sensations from your legs to your brain.

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Femoral Nerve Palsy After a Total Hip Replacement

Mangiarelli Rehabilitation physical therapy patient Kay underwent a total hip replacement of the right hip in May 2022. However, in June 2022, Kay underwent a revision due to the hip dislocating. One month later, in July 2022 after the revision surgery, Kay retained femoral nerve palsy, which caused significant weakness in the thigh. Throughout the fall of 2022, Kay began walking with a walker while wearing a brace for support. Now, in May 2023, one year after the initial hip replacement, Kay no longer wears a brace. Her quadriceps strength is returning, and she is now walking with speed with a walker and with a single cane.

While femoral nerve palsy after a total hip replacement is a rare occurrence, it is a serious complication post-hip surgery and requires extensive and comprehensive rehabilitative support. A total hip replacement involves removing damaged bone and cartilage in the hip and replacing it with prosthetic components: the damaged femoral head is removed and replaced with a metal stem that is placed into the hollow center of the femur. During the surgery, the femoral nerve can be compressed and injured due to surgical manipulation and retractor placement, tensions from limb lengthening, compression from a post-operative hematoma, or as in the case of our patient, hip dislocation post-surgery.

The risk of experiencing femoral nerve palsy post-hip replacement can increase if the patient has hip dysplasia, lengthening of the leg during the surgery, use of a uncemented femoral component, or being female, which may be related to differences in female muscle mass, local vascular anatomy, and shorter limbs. In a meta-analysis of 34,000 total hip replacements, females had a 1.5% risk of nerve palsy while males had a 0.77% risk.

Symptoms of femoral nerve palsy can include pain that radiates from the back and hips into the upper thigh; numbness, weakness, and tingling in the thigh, lower leg, ankle, and foot; lower back, hip, and groin pain; difficulty straightening the knee and leg; muscle loss and weakness in the leg, particularly in the quadriceps; loss of sensation in the upper leg and lack of coordination; feeling that the leg or knee is going to give out or buckle; and walking and gait problems.

A recent 2018 review of 17,350 primary total hip replacements from 2011-2016 found that the overall incidence of femoral nerve palsy was 0.21% after surgery; however, the incidence of femoral nerve palsy was 14.6-fold higher in patients who underwent anterior hip surgery. The researchers found that significant recovery from femoral nerve injury did not commence for the majority of patients until greater than 6 months post-surgery. However, motor weakness resolved in 75% of patients within 2.5 years with the remaining 25% experienced mild residual weakness that did not necessitate an assistive walking device or brace. Recovery from femoral nerve palsy can be unpredictable, but the majority of patients who suffer from femoral nerve injury after hip surgery go on to recover, regaining muscle strength and fairly normal walking function after physical therapy.

Returning to Walking After Femoral Nerve Palsy with Physical Therapy

Physical therapy after a total hip replacement and femoral nerve palsy is essential. A physical therapist can help reduce compression on the nerve and help patients safely and gradually regain quadriceps muscle strength, relieve nerve pain, and improve walking ability.

In the video below, Mangiarelli Rehabilitation physical therapy patient Kay demonstrates her incredible progress over the last year, recovering from hip surgery, revision surgery, and femoral nerve palsy. Kay has progressed from using a leg brace with a walker to walking with a walker without the brace and now walking with a cane:

Physical therapy treatment to address femoral nerve palsy can include:

• Manual therapy hands-on soft tissue and joint mobilizations to gently move muscles and joints, particularly the hip, thigh, and knee. The therapist may also perform neural mobilizations to restore movement in tissues and nerves and relieve pain.

• Range of motion exercises address back, hip, and surrounding muscle tightness and limited mobility which can increase pressure on the nerve. The therapist teaches the patient gentle stretches to decrease muscle tension and restore normal movement in the back, hip, and leg.

• Muscle strengthening, particularly of the hip, pelvic, and core muscles as well as the quadriceps muscles. Muscles weaknesses linked to hip or pelvic injury can cause nerve compression. The therapist may implement active ankle and counter-resistance exercises, isometric exercises of the quadriceps and gluteal muscles, and trunk control strengthening and exercises. The therapist may also do quadriceps electrostimulation during isometric exercises to stimulate the quadriceps muscles, which can be negatively impacted by femoral nerve palsy.

• Use of orthotics and knee brace for added support of the leg as the patient begins to walk.

• Gait training to restore normal walking patterns, starting with the use of a brace and walker before progressing to a cane and then to no assistive devices when walking as the patient gains strength.

Femoral nerve palsy after a total hip replacement can be debilitating and limit your mobility and return to function. Working with a physical therapist is essential to address femoral nerve palsy and regain strength and walking ability safely!