Marisa Perdomo PT, DPT, CLT-Foldi, CESAs many of you know, EDUCATA and the Oncology Section of the APTA have recently launched a major course on the management of edema. This course is also a key component of the Certificate of Achievement in Oncology PT (CAOPT) program from the Oncology Section. We are now very pleased to bring you the lead educator in this series, the distinguished Marisa Perdomo PT, DPT, CLT-Foldi, CES, and faculty at the University of Southern California. In this series, she discusses a specific edema case in three parts. So enjoy! And please join with your input in response to her provocative questions.

— Marilyn Pink, PT, Ph.D.


You can earn CE credits by reading all three posts in this series! To earn two hours of credit, you will also need to read the below articles, purchase the course, and take the pre- and post-tests to earn your two credit hours!

Download course outline.


MANAGING A CASE OF ORTHOPEDIC EDEMA

Peripheral edema is a common impairment after surgery and injury, and, in particular, total joint replacement surgery. Peripheral edema causes pain and tightness, as well as loss of joint motion; it inhibits muscle recruitment and therefore impedes muscle strengthening and function. Additionally, the presence of peripheral edema slows the healing process and may result in an increased number of physical therapy visits. In other words, the prolonged presence of peripheral edema negatively impacts an individual’s ability to return to full pain-free activities.

The causes of peripheral edema can be very straight forward, such as in post-surgical edema. However, peripheral edema can also be caused by many systemic conditions, for example, RA and chronic venous insufficiency.  Additional impairments to various organs, such as undiagnosed congestive heart failure, as well as liver and kidney dysfunction, can also lead to peripheral edema. All of these “systemic conditions” may also contribute to the amount of edema present following a typical orthopedic surgery.

The following case presentation:

  1. Demonstrates the potential complexity in determining treatment interventions for peripheral edema in a “simple” total hip case, and
  2. Discusses how the combined interventions of manual lymphatic drainage, exercise, and home program can significantly reduce post-operative peripheral edema in a short amount of time. These techniques can be used across the continuum of care in any stage of healing and in any patient setting.

Setting: Home Health Physical Therapy

Mark is a 59-year-old male who underwent a right total hip replacement 10 days ago. PT referral: evaluate and treat: total hip protocol with posterior-lateral approach; weight bearing as tolerated; limit hip adduction to neutral, and flexion < 90 degrees.

Mark has a 10-year history of bilateral hip OA with the left hip replacement 8 years ago.

Lateral view of the hip incision

Lateral view of the hip incision

The initial evaluation revealed:

  • ADL: Stand-by assistance with all bed mobility activities; manual support to right leg during supine to sit to stand to sit transfers.
  • Gait: Independent household ambulation ~ 100 feet with walker and partial weight-bearing on right lower extremity.
  • Equipment: Raised toilet seat, shower handle, cane, walker, reacher and hook.
  • Medications: Tramadol, Acetaminophen, Coumadin and Omeprazole.
  • Social History: Married, two college-age children. Wife has taken two weeks off of work to take care of Mark.
  • Employment: Certified Public Accountant.
  • Observation: Incision with staples, edematous with serious drainage and dressing; no signs or symptoms of infection. Edema present @ the incision, buttock and upper thigh/groin region on right.
Right leg edema present

Right leg edema present

What can we say about this image?

What can we say about this image?

  • Nursing: 3 visits scheduled for assessment of incision and to perform dressing changes; scheduled blood draws for INR.
  • Functional Strength Assessment:
    • Unable to perform a right straight leg raise; + extensor lag on right.
    • Able to perform a partial bridge.

Comments: This is a straightforward clinical presentation of an individual s/p THR. Mark knew what to expect as a result of his previous left total hip replacement and was not fearful of challenging himself to be as independent as possible.

Before you move on…

Dr. Perdomo recommends reading the following articles to gain a deeper understanding of treating orthopedic edema. If you are taking this course for credit (you can purchase the course here), this reading is required.

Now, it’s YOUR turn:

After any orthopedic surgery, edema is expected.

  1. What interventions or strategies do you presently employ to treat post-operative edema following a total hip procedure in the home health setting?
  2. After examining the pictures of Mark’s right hip edema, do you consider the amount of edema as expected? Provide your clinical rationale.

Enjoying this case study? Once you’ve had a chance to reflect and comment below, continue to the second part of Dr. Perdomo’s case study.

This article has 8 comments

  1. Prerna

    I have few more questions: In this case it’s not been mentioned about the thorough PT interventions. What sort edema it is? The grade would help to formulate a treatment plan. How long the limbs were being elevated? Were the proximity congestion was cleared before draining distally? Moreover, omeprazole is a drug used for peptic ulcer so what other systemic condition does patient have?

    As edema is unclear and PT interventions didn’t worked out the patient should be consulted to the physician.

  2. Joss

    In looking at the images, it looks to me that the edema does not quite fit/match the precipitating event (surgery). Is there some other condition present?

  3. Amanda

    Many more questions: Am I missing the health history, I don’t see it anywhere? Does the patient have any other current signs or symptoms (fever, pain)? What is his INR?

  4. Claire

    I use a combination of manual therapy and exercises to treat post-surgical patients with edema. I found that if I reduce pain and edema with manual therapy prior to the exercises, the patients regain ROM, strength and function faster.

  5. Martyny

    A good choise would be a usage of kinesiotaping (for exapmle lymph technique) which should reduce edema quite fast. The edema might be the couse of restricted ROM. Reducing it would accelerate healing proces.

  6. Anne Kenny

    My treatment approach is similar to Claire’s for Hip and Knee replacements.
    Use Manual therapy / Soft tissue Treatment prior to exercise ROM, Muscle reeducation, motor control and strengthening. Modalities Quick Icing tech, Icing, Functional Electrical Stimulation are also utilized as indicated.

    Education of patient on Effective Pain management and Oedema Management techniques to facilitate healing response.

    Team approach with the Physician re Medications to facilitate the healing process with Therapy.

  7. Paule

    I have no idea what a “PTH” is even if written total hip replacement.
    Perhaps the person has an alien growing in his hip?

  8. Marisa Perdomo

    Thank you so much for your great comments and questions. The goal for part I, was quite simply, does the presence and description of the edema match what a therapist would expect from a total hip replacement and then secondly to get an overview of how today’s PT’s are treating peripheral edema. Good to see kinesio-taping in the choices as well as all the other standards.

    Nice comprehensive intervention list. The rest of the case will build on these and other interventions for the edema.

    You’ll are correct, more information is needed with respect to medical history and co-morbidities. For the medication Omperazole, it is also used to treat acid reflux.

    I am searching the case for “PTH” and can’t find it but i am sure it was a typo. I did find the abbreviation s/p THR.. status post total hip replacement…

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