Hip Pain

How do we treat hip pain?

As always, comprehensive examination to enlighten the source of the pain (the inflamed body part) and the cause of the pain (the biomechanical forces that cause the strain to occur), are the cornerstone to effective management programmes. Because of the variance in conditions, particulars of cause and treatment are discussed individually below.

What is referred “hip” pain?

Pain experienced over the iliac crest (where you rest your hand on your “hips” in standing) and buttock is a common component of spine-related problems. The pain may be referred to the “hip” in absence of local hip pathology, and/or, there may be spasm, tightness and inflammation in hip and buttock muscles as result of faulty spine and pelvis biomechanics. It can be seen that spine and pelvic problems perpetuate hip muscle problems, and vice versa. For this reason, the hip and associated muscles are essential to consider and examine in any spine/pelvis problem, and vise versa.

What is hip bursitis?

This is an over-used label that has become synonymous with any painful condition that affects the buttock muscles and/or their insertion into the trochanter on the side of the hip. True “bursitis” means inflammation of a bursa, which is a fluid sack that lies interposed between moving surfaces to facilitate smooth gliding. This can be seen on diagnostic ultrasound. While there are many bursae around the hip and pelvic region, most cases of “bursitis” as diagnosed by the medical profession are not true bursitis. Many cases of so-called bursitis are related to muscle imbalance in pelvic stabilising muscles whereby one muscle becomes tight and tense from overuse and another becomes under-utilised and weak. It is usually the over-used muscle that produces symptoms, and similar histological findings are seen in the insertion of these muscles to bone, as is seen in patellar tendinopathy and Achilles tendinopathy. Examination requires thorough biomechanical exploration of the spine, pelvis and hips. This gives structure to the treatment. Diagnostic ultrasound is now used to directly visualise the deep stabilising muscles of the hip and pelvis to aid diagnosis and treatment. Various hands-on techniques apply, as well as a range of stretching, strengthening, re-training exercises for local hip muscles. Other issues such as pelvic stability and lower limb alignment must be addressed. Orthotics are often of benefit to control leg alignment and muscle recruitment patterns in the buttock.

What is hip arthritis?

This literally means inflammation of the hip joint, and like many terms used commonly in medicine, need some interpretation. Most cases of hip arthritis are aseptic (non-infectious) wear-and-tear degeneration that develop silently over many years through misalignment, sporting abuse, past injury, or genetic predisposition. The question that needs to be asked here, is it the ‘genes’ that are inherited or the posture, lifestyle diet and other underlying causes that are inherited? Hip arthritis is common in advanced years, but may be experienced in younger years in ex-athletes that load the hip joint, e.g. footballers, ballet dancers, or in people with congenital problems in the joint, e.g. Perthes disease. In early onset hip arthritis, it is often the stiffness and associated disability that causes concern, before the actual hip pain (often in the groin).

Lumbar spine and pelvic pain is a common presenting feature of early onset hip arthritis, presumably due to attempts to compensate for lost hip mobility. When the hip joint cartilage lining wears out, the capsule tightens and the muscles that support the joint waste. The process may happen in the opposite order, but these are common associated findings. Hip arthritis can’t be reversed, but sometimes treatment can slow the rate of deterioration and reclaim some function. Treatment in the early stages requires hip joint capsule stretches, muscle stretches, stabilising muscle re-education, as well as attention to any underlying biomechanical or misalignment problems. Activity modification may help prolong improvement. Glucosamine has been shown to be helpful in some cases with little evidence of side-effect, and certainly less side-effect than prescribed anti-inflammatory medication. Joint replacement technology is most advanced in the hip joint where a younger patient may benefit from a resurfacing procedure, whereas an older patient would undergo a formal hip replacement.

What sporting conditions are seen in the hip?

Ballet dancers, gymnasts and other combined flexibility/power athletes seem to be prone to hip problems. Ballet dancers in particular (depending on the school) use a strong hip turn-out and tend to stand with a posteriorly rotated pelvis and so ‘hang’ on the ventral aspect of their hip joints. Instability problems and labral injury are common. Significant labral lesions that don’t respond to conservative treatment may require surgery. Footballers are prone to musculoligamentous problems in the hip and groin area, as well as the dreaded ‘football cancer’ called osteitis pubis. This condition has evolved with the advent of improved imaging techniques such as MRI. The precise cause is unknown, but many underlying biomechanical, flexibility, symmetry, stability, training issues are considered to significant in cause.