Hip pain and injury assessment and treatment guidelines

Hip injuries though less common due exist specially for the contact athlete.  To date assessment whether by objective tests or by imaging studies has been less sophisticated in identifying pathology.   The increased use of hip arthrosopy surgery has allowed clinicians to learn more about intra-articular (within the joint) disorders that were undiagnosed or not properly understood in the past.  We will look at common hip joint pathologies, methods of assessing dysfunctions and the treatment options available.

Common intra-articular hip pathologies common to the contact athlete:

1. Labral tear
2. Degenerative Joint Disease or arthritis of the hip joint
3. Ruptured or impinging Ligamentum teres
4. Instability of the hip joint
5. Loose bodies within joint
6. Chondral (pertaining to cartilage) injuries
7. Femeroacetabular  (the hip ball and socket joint) injuries
8. Impinging osteophytes (bone growths)
9. Synovial (connective tissue lining) pathologies

Extra-articular structures responsible for hip pain

1. Psoas bursitis
2. Ischial bursitis
3. Trochanteric bursitis

Muscular injury around the hip joint:

1. Iliopsoas strain
2. Sartorius strain
3. Gluteal strain
4. Iliotibial facia
5. Quadriceps strain
6. Hamstring strain
7. Adductor strain

Local structure involved or referring pain around the hip joint.   Hip pathology can co-exist with other pathologies.

1. Lumbar spine (low back) dysfunction (L2-S1) can refer pain to the hip.
2. Sacro-iliac joint pathologies or misalignment can refer pain to the hip.
3. Misalignment or dysfunction of the knee, ankle and foot could also contribute to hip problems.

Common presentations of Hip pathology:

1. History of trauma is not always present.  Can be due to cumulative wear and tear secondary to excessive load or use of the joint.
2. Subjective complaint of giving way, catching, locking or sharp pain.  Clicking or popping sounds within or around the hip/pelvis area.
3. Increased pain with twisting movements especially in weight bearing positions such as walking, running or during athletic activities.
4. Prolonged sitting with the hip flexed causing pain.
5. Going from sit to stand is often painful.
6. Getting in/out of car seat or up/down from low surfaces can be painful.
7. Often unable to squat or have difficulty bending to tie shoes and socks.
8. Turning in bed can be painful with “catching” sensations.
9. The joint could be red, hot, swollen or cool to touch.  Can also have soft tissue thickening of the surrounding structures.

*Classic presentation of hip joint pathology presents as anterior (front) groin pain radiating down to the medial (inside) thigh.

Clinical examination should involve in depth subjective and objective examination.   Some things to consider when trying to determine the cause and before establishing a treatment plan.

1. Observation: if one leg is longer than the other, presence of scoliosis, or gross asymmetries in the pelvis, etc.
2. Must rule out the low back as the source of the problem.
3. Specific standing and supine movement and functional tests to determine involved structures.  Strength and mobility tests of the local muscles and joints must be done.
4. Should assess joint and muscles above and below the hip joint to make sure other structures are not contributing to the problem.

Treatment focuses on improving mobility, strength, motor control and coordination of the joint and muscles in the whole kinetic chain.  Addressing joint problems or mal-alignments above or below the hip is extremely important to gain lasting relief from the problem.  The whole system works together and if one part is poorly functioning it will invariably stress and affect all other structures.

Conservative management involves therapeutic exercise starting in non-weight bearing and progressing to a protected weight bearing protocol.  Special attention is paid to restore balance between the Hip Flexors and Hip Extensors.  Quite often hip pathologies present with tight Hip Flexors and Erector Spinae with inhibition or weakness of the Gluteals and Abdominals.   A focused program with stretching and strengthening exercises to restore balance between antagonist muscle groups combined with soft tissue and joint mobilization techniques to manage pain and improve tissue health can be administered by an experienced Physical Therapist.

The patient has to be educated on a sound and safe home exercise program coupled with specific instructions for avoiding the aggravating activities.  If weight bearing is a problem, use of a cane or crutches is highly recommended.  The injured tissue has to be given time to heal if optimal recovery is desired.  If conservative treatment fails, orthopedic surgical management should be sought to prevent excessive wear and tear on the adjacent body parts.

*This information is for education purposes only.  Please consult your Physician, Physical Therapist or Wellness Practitioner before starting any rehabilitation, wellness or fitness program.  These statements have not been evaluated by the FDA.  These products are not intended to diagnose, treat, cure, or prevent any disease.

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