Hip pain is a very common musculoskeletal complaint across all age groups. It varies highly person to person and it can affect people with all types of activity levels. As the hips are being constantly used and loaded throughout the day they can be susceptible to injury. Therefore with activities like sitting, standing and walking involving and influencing the hips, it is essential that they are pain free, mobile and functioning well.
The hip joint is a ball and socket joint which is made up of the femoral head at the top of your thigh bone (ball aspect) and the acetabulum of the pelvis (socket aspect). The joint is surrounded by ligaments, muscles and a joint capsule. These structures work together to provide stability, structural support and movement to the joint.
The hip joints are also highly integrated with your pelvis and sacroiliac joints along with your lumbar spine. Your hip function can also be influenced by biomechanical or compensatory changes in the lower limb joints.
So given that the hip joint is a complex region it is especially important that it is assessed thoroughly and appropriately to determine any dysfunction. Your highly trained Physiotherapist will complete a thorough assessment of your hip joint and any other appropriate structures. Some of the areas they may assess are below:
- Hip range of movement +/- other lower limb joints
- Hip orthopaedic tests
- Muscle strength and activation
- Muscle length or flexibility tests
- Functional assessments (eg. Walking, sitting to standing, running etc.)
- Lower limb biomechanics
- Lower back assessments
Causes of Hip Pain
There are many different causes and structures responsible for hip pain or dysfunction. They can range from acute to chronic and from age-related reasons to sporting injuries. Some of the most common acute and chronic causes are below.
Typically a more acute episode of pain and can occur through various muscle groups around the hip joint. Most tendonitis presentations will be affecting the gluteal muscles at the back and/or the outer side of the hip, at the front of the hip through the hip flexors/quadriceps or in the groin area via the adductor muscle group. This can occur in conjunction or subsequent to a muscle strain or can occur with an acute overload injury.
Can occur to any of the muscle groups around the hip and can be caused via an acute trauma or they can be a progressive overload type injury to the muscle.
Trochanteric bursitis is an inflammatory condition of the bursa that lays over the prominent aspect of bone on the outside of your hip. The bursa is a small, fluid filled sac that sits over prominent areas of bone to act as a shock absorber and also to reduce friction. Typically occurs as a result of increased compression and irritation to the bursa via the surrounding musculature being weak or tight.
Trochanteric bursitis can result in symptoms such as; pain to the outside of the hip, pain referred down the thigh, pain when sleeping on your side and pain when standing from a sitting position.
FAI – Femoroacetabular Impingement
FAI is the term used for the impingement between the femoral head and the acetabulum, so the ball and socket of the hip joint.
There are 3 types of FAI; they are a Pincer or a Cam impingement or a combination of both.
Pincer impingement occurs when there is a bony change to the acetabulum (socket).
Cam impingement occurs when there is an additional bony growth to the femoral head.
Both of these impingements are caused by the ball and socket joint not moving smoothly due to the extra bony growths.
The symptoms of FAI typically include; pain to the hip or groin, pain with prolonged walking or sitting especially with the legs crossed, as well as reduced range of movement in the hip joint. However most of the time the hip joint needs to be provoked in order for this condition to become painful/symptomatic. There is a higher tendency for this to occur in sporting and highly active people, however can occur secondary to weakness of the hip musculature.
There are 2 main tendinopathies that occur around the hip joint, these are gluteal and adductor tendinopathies. These types of tendon injuries may seem to happen suddenly, but they are usually a result of repetitive micro tears to the tendon which have happened over a period of time. The micro tears develop from the tendon being stressed by repetitive loads that are greater than what the tendon can withstand.
These injuries can occur in 3 areas of the tendon, the musculotendinous junction (where the tendon joins the muscle), mid-tendon or at the tendon insertion (where the tendon inserts into bone).
Gluteal Tendinopathies relate to a type of injury to the gluteal tendons which connect your glute muscles to your hip bone. Gluteal tendinopathies are the most common tendon injury to occur at the hip joint. They can present with lateral hip pain, muscular tightness and weakness to the hip muscles.
Adductor Tendinopathies are related to the repetitive tendon injury to the adductor muscles in the groin, which sit on the inside of the thigh and their main role is to bring the legs together. This condition typically presents with pain in the groin or the inside of the thigh and pain with bringing your legs together against resistance. Most commonly seen in sprinters, football players and horse riders.
Hip Osteoarthritis is a joint disease which mostly affects your joint articular cartilage, causing it to deteriorate and wear away over time. Articular cartilage covers the joining sections of bone within a joint to allow for smooth gliding of the bones against each other. It also acts as a shock absorber to reduce the shock forces being dispersed into the surrounding hip musculature.
Muscle weakness and the subsequent hip joint instability is thought to be a main contributor to the break down and the rate of deterioration of articular cartilage. Some other risk factors that may affect cartilage deterioration include; being overweight, age, previous injuries to the joint and the stresses that have been placed on the joint over time eg. work or playing high level sports.
In order for the treatment of hip pain to be effective it is important that the cause or condition responsible for the pain is correctly diagnosed, as this will influence the management plan prescribed. Your Physiotherapist is highly trained in the assessment and resulting treatments of hip conditions which will enable an effective and accurate rehabilitation of your hip pain.
Each of the hip conditions will have different treatment goals and focuses depending on the type of injury, mechanism of the injury as well as the area of injury.
Some of the types of treatment your Physiotherapist may give you are below:
- Advice and education on activities to do and activities to avoid, load management (to avoid further tendon irritation) as well as self-management strategies
- Gait retraining – to reduce the stresses and strains on the hip from walking, running or other activities
- Tendon strengthening exercises – isometrics, gentle loading exercises and movement retraining
- Specific strengthening exercises for the hip and core muscles
- Massage and/or Dry Needling to reduce muscle tightness
- Joint mobilisations
- Stretches and mobility exercises
- Return to sport/work programs if appropriate
The hip joint is a complex joint that is highly integrated with many other structures that surround it. This complexity means that there are various causes and types of pain in the hip, and it is important that these are properly assessed and diagnosed by your Physiotherapist in order for the appropriate management to be completed. The management plan your Physiotherapist prescribes will be specific to the findings of your assessment and the nature of your pain/symptoms. Below are some general tips on how self-manage your hips to reduce the chance of injury.
General tips for hips:
- Keep moving; try to keep changing positions, move between sitting and standing positions to reduce the time spent in each position
- Regular stretching of the hip, especially if you are in a sedentary job or if you are very active
- Avoid crossing your legs when sitting for long periods
- If returning to exercise ease yourself into it over time to reduce the chance of aggravating the hips.
- Most importantly – Don’t ignore any twinges or niggles, as mild as they can be, it is best to get it looked at by a Physio to avoid it becoming a bigger issue.