Pain around the hip is common for all age groups. The hip joint’s integration with the pelvis, sacroiliac joint (SIJ) and lumbar spine (lower back) makes it a complex region to correctly analyse and assess any dysfunction.
Hip function can also be affected by low back and lower limb biomechanics involving the knee, foot and ankle, as well as the thigh and calf muscles.
Common hip conditions include:
Hip Osteoarthritis
Hip osteoarthritis is a common degenerative condition. It mostly affects the articular cartilage which allows the bones to glide smoothly and painlessly over each other, while also helping to absorb shock. Hip OA is characterised by the degeneration of this articular cartilage, causing the cortical bone below to become exposed.
OA is diagnosed with x-ray, which will show a loss of joint space and changes to the bony surfaces of the joint.
In July 2018, the Royal Australian College of General Practitioners published new guidelines for the management of hip and knee OA. These guidelines confirm that exercise and weight management are the best treatments for OA. Specifically, land-based exercises such as walking, strength training and tai chi, are recommended. Treatments such as heat, massage, hydrotherapy and medication can also be used for OA but should only be used as adjunct treatments to exercise and weight management. For hip OA specifically, it has been found that patients who participate in a regular strength program are less likely to have a hip replacement, or are able to prevent the need for a hip replacement for a longer period of time (Sverge et al, 2013).
Before commencing an exercise program for OA it is important to consult a physiotherapist. A thorough physiotherapy assessment will allow for the development of an appropriate exercise program, based on symptoms, functional limitations, personal preference and goals.
Svege, Ida, et al. “Exercise Therapy May Postpone Total Hip Replacement Surgery in Patients with Hip Osteoarthritis: a Long-Term Follow-up of a Randomised Trial.” Annals of the Rheumatic Diseases, vol. 74, no. 1, 2013, pp. 164–169., doi:10.1136/annrheumdis-2013-203628.
Total Hip Replacement
A total hip replacement is a common surgical procedure, where the head of the femur and the hip socket are replaced with artificial substitutes. The hip is a ball and socket joint, where the head of the femur is the ball that fits into the hip socket. Most commonly, total hip replacements are a treatment option for hip osteoarthritis once physiotherapy management is no longer enough to minimise pain.
Another common reason for a total hip replacement is to fix a broken hip following a fall. In this case, it is an emergency procedure and there is no option to trial physiotherapy prior to surgery.
Following THR surgery, patients will be treated by a hospital-based physiotherapist until discharge. Initially, physiotherapy is focused on mobilisation out of bed within the first 12-24 hours of surgery. This may begin with just sitting on the edge of the bed, standing at the bedside or taking a few steps with a forearm support frame. Over the next few days, physiotherapy involves regular walking with a walking aid, range of motion exercises and gentle strengthening exercises.
Following discharge, a strict exercise program of range of motion and strengthening exercises should be followed, both at home and under the guidance of a physiotherapist. These exercises are often required to be performed multiple times daily to avoid post-surgical stiffness and allow a full return to normal daily activities and hobbies.
At Hawker Place Physiotherapy and Pilates, we provide individualised exercise programs for patients who have had a THR, regardless of the length of time since surgery. Prior to THR surgery, undergoing a pre-operative rehabilitation (“prehab”) program of strengthening and mobility exercises may also improve early post-operative pain and function.
Gluteal Tendinopathy & Trochanteric Bursitis
Gluteal tendinopathy and greater trochanteric bursitis are often grouped under the term greater trochanteric pain syndrome (GTPS) despite being different conditions. Symptoms of both gluteal tendinopathy and greater trochanteric bursitis are very similar. There will generally be pain and tenderness over the lateral hip bone as well as pain when lying on that side.
A gluteal tendinopathy is a common cause of lateral hip pain. Tendons are tough fibrous structures that connect the muscles to bones. Gluteal tendinopathy is a degeneration of the tendon caused by repetitive overloading. It is a common condition both in athletes and in the older population. Treatment involves modification of activity to reduce the load on the tendon and a gradual strengthening program guided by your physiotherapist.
Greater trochanteric bursitis is an inflammation of the bursa that sits on the hip bone. A bursa is a fluid-filled sac that acts to absorb shock and minimise friction between the soft tissues and bone. Greater trochanteric bursitis has a gradual onset and progresses over time due to overuse, increased friction, too much pressure or direct trauma. In most cases treatment consists of reducing aggravating activities and a strengthening and stretching program with a physiotherapist. Ice and anti-inflammatory medications can also be used to help reduce inflammation and pain.
Stress Fracture
Stress fractures occur in bones when they cannot tolerate the amount of mechanical load being placed through them.
Bones are constantly in a cycle of breakdown and repair (known as bone resorption and bone formation). Stress fractures occur when repetitive loads placed through bones lead to an imbalance between the two processes – with a higher rate of breakdown than repair.
Stress fractures will usually begin as a microscopic crack in areas of greatest stress, if the bone continues to be loaded and not heal, this can lead the crack to enlarge.
Many factors can contribute to bone stress fractures including; high repetitive activity levels, osteoporosis, radiation therapy, hormone imbalances, poor nutritional status, and bone quality.
Stress fractures of the hip most commonly occur in runners at the femoral neck. Symptoms include pain at the front of the hip or groin. Pain will initially be present during running, however, in more severe cases, pain can become more constant.
Hip Labral Tear
The labrum of the hip is a cartilaginous ring that lines and deepens the socket and improves hip joint stability. Tears to the labrum can occur in sports involving repetitive activities such as kicking and dancing. People with other hip conditions, such as femoroacetabular impingement or hip dysplasia, have a higher risk of labral tears.
Labral tears are often characterised by deep pain towards the front of the hip or groin, aggravation of pain with movement and clicking, catching or giving way of the limb. Your physiotherapist or doctor may refer you for further imaging in order to assist in diagnosis of a labral tear.
Pelvic Girdle Pain during Pregnancy
Low back and pelvic girdle pain are common side effects of pregnancy. Pelvic girdle pain can occur at any stage of pregnancy, however, it is more common in the third trimester. It is important to know that pelvic girdle pain will not harm your baby, though it can result in a lot of pain for you.
Pelvic pain can occur at the front or back of the pelvis and can occasionally refer into your hips or thighs. The cause of pelvic girdle pain during pregnancy is believed to have multiple contributing factors including; hormonal, physiological and postural changes. As your baby grows the increased weight can change your posture when you sit or stand, increasing stress on the pelvis. Your physiotherapist can provide you a range of exercises, strategies, and therapies to help you to manage your pelvic girdle pain during pregnancy.
Osteitis Pubis
Osteitis pubis is an inflammation of the pubic symphysis. The pubic symphysis is a cartilage joint that joins your left and right pubic bones together. Its role is to keep the two bones of the pelvis steady and together during movement and activity. Symptoms include pain over the pubic bone which can also refer into the groin region. Often pain will also be reproduced with coughing, sneezing and during sit ups. Osteitis pubis is a common cause of groin pain in athletes in the football codes. Your physiotherapist will recommend a period of rest, alongside a rehabilitation program consisting of specific stabilisation exercises of the pelvis. Once symptoms start to improve, your physiotherapist will recommend a graded return to your sport or activity
Sciatica
Sciatica is a term used to describe pain along the distribution of the sciatic nerve, which runs from the lower back, through the buttock and down through the back of the leg. Sciatic pain is caused by irritation or pinching of the sciatic nerve.
Irritation or pinching of the sciatic nerve can be the result of many different pathologies. These can include entrapment from a herniated disc in the lumbar spine, spinal canal stenosis, arthritic conditions, fractures, spondylolisthesis (a slipping of the vertebra) or even just stiffness of the lumbar spine or tightness of muscles surrounding the sciatic nerve.
Patients with sciatica may experience radiating pain or altered sensation such as pins and needles or numbness. In more severe cases, muscles throughout the leg may also become weak.
Your physiotherapist will perform a comprehensive assessment of your range of motion, movement patterns, neurological structures and strength. Treatment will often include manual therapy, soft tissue massage and gentle strengthening and mobility exercises.
