The Irritable Hip

By Principal Physiotherapist Amanda McDonald

Hip pain is a common issue posing threat to a person’s overall wellbeing, function and quality of life. The hip is one of the most important joints in the body. With its primary role in movement, balance and stability, it also supports the trunk and upper body.

The hip region is prone to various types of injury that can affect the person’s ability to move and function. From acute to chronic pain we commonly we see hip pain which can derive from a variety of biomechanical, nervous, arthritic, cancer and trauma related issues.

Hip pain can be caused by the joints and bones, muscles, or referral from the lower back and pelvis. It may be caused by a traumatic injury or develop over time with wear and tear or abnormal loading/biomechanics over time. Fractures are common in the elderly population or from ongoing inflammation in the hip joint from a variety of issues.

Arthritis

Arthritis is one of the most common causes of chronic hip pain. The disease causes the slow deterioration and gradual wearing down of the cartilage, reducing the cushioning capacity and distribution of forces leading to pain, inflammation, reduced range of motion, strength, and function.

The most common types of arthritis are Osteoarthritis, Rheumatoid Arthritis, Psoriatic Arthritis and Septic Arthritis. Osteoarthritis can usually be managed well with physiotherapy treatment as ensuring good joint mobility and recovery of strength can help immensely.

Traumatic Hip Injuries

The most common causes of trauma to the hip include acute sporting injuries, sudden falls, and car accidents. All age groups can experience these injuries no matter how healthy their joints, muscles and bones are. Fractures of the hip and bones are common and are commonly managed with surgical intervention. The most common traumatic injuries include hip fractures, dislocations, femoral acetabular impingement (FAI), and labral tears of the hip cartilage.

Commonly the muscles of the hip and lumbar spine go into muscle spasm and ‘protect’ the joint. This can lead to an increase in pain, reduced mobility and function. Physiotherapy treatment and exercise aims to reduce muscle spasm and retrain the muscles surrounding the hip, reducing the chance of re-injury.

Biomechanical and postural issues

Hip pain can be provoked by misalignment issues in the pelvis and hip. We commonly see pelvic positional faults which can be caused by habitual patterns such as hip hanging, postural issues, holding patterns or guarding the hip, poor movement biomechanics, weakness in the hip and pelvis. The muscles can ‘grip’ in this positional misalignment creating trigger points in the hip and consequently pain.

Physiotherapy aims to realign the hip and pelvis, retrain the muscles, and educate the patient on how to avoid this in the future. Pilates exercise is an excellent way to strengthen the body and create a strong foundation, preventing re-injury.

A ‘grippy’ pelvic floor

In some cases the muscles of your pelvic floor can be weak, but in other cases ‘tight’ or overactive. A ‘grippy’ pelvic floor can impact your back, pelvis and hip directly through their attachments onto the pelvis, causing pain. Commonly we see this due to postural imbalances and asymmetries in the pelvis, and there are many causative factors from both a physical and psychological stand point. One of the hip muscles obturator internus can be involved in the hip dysfunction. This muscles is easily palpated via an internal examination via the pelvic floor.

Nerve Injury

The most common nerve injuries of the hip include sciatica and neuralgia. Nerve injuries are a result of a nerve becoming irritated or compressed by an increase in pressure or friction surrounding the nerve. An example of this would be when a nerve becomes compressed within a tight muscle or fascia due to repetitive stress or sudden trauma. As a result symptoms may present such as burning, tingling, numbness, resulting in pain and weakness of the muscles which are innervated.

Other causes of hip pain

• Cancer: Although relatively rare, cancers can cause hip pain. This pain may come on quite acutely for no explained reason or can manifest with existing hip pain. With thorough assessment it can be identified and managed appropriately. Some of the cancers known to cause hip pain are bone cancer, Chondrosarcoma and Leukemia.

• Avascular Necrosis: This occurs when the blood supply to the bone becomes impaired, creating deterioration and break down of the bone tissue. Consequently this can hip pain and loss of mobility and function. Predisposing factors to this include trauma to the bone ie fracture, infection, or excessive use of steroids and excessive alcoholism.

• Osteoporosis: Is a condition in which the bones become brittle and fragile from loss or slow growth of new tissue, typically as a result of hormonal changes or reduction in calcium and vitamin D. It occurs when the growth of new bone isn’t fast enough to replace the old bone tissue. The weakness of the bones means that even low impact activity can increase the likelihood of fracture.

• Synovitis: Occurs when the synovial membrane (sac filled space) within the synovial space thickens and consequently causes pain. This is common in children under ten years of age.

Common Symptoms of Hip Pain

The symptoms of an irritable hip include the following:

• Pain directly around the hip. This may include at the front, side or buttock area. It may also refer down to the knee and foot or up to the lower back.

• Groin pain

• Swelling and tenderness on palpation.

• Loss of mobility and inability to move the hip well through space. Also difficulty doing ADLs such as in/out of bed, walking, getting out of a chair, going up stairs.

• Reduced weight bearing on the affected leg eg limping

• Poor balance on the affected leg

Hip Pain Treatment

Hip pain is treatable through a variety of methods including:

• Manual therapy and muscle energy techniques

• Dry needling

• Joint mobilisation

• Specific exercises and stretching

• Pain education and medical advice using NSAIDS and pain relief (as liaised with your GP)

Hip pain physiotherapy is an effective treatment that can alleviate pain as well as facilitate long term recovery. Specific physiotherapy techniques aim to increase quality and range of movement, and relieve pain. We use Clinical Pilates exercises to retrain the muscles surrounding the hip in a lot of cases including pre and post operatively.

Image via Harvard Health and © Jan-Otto/Getty Images