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PHYSIOTHERAPY MANAGEMENT
OF COMMON HIP JOINT CONDITIONS
IN THE PRIMARY CARE SETTING
by Margaret Hanlon MSc, BSc(Hons), MISCP
Hip joint pain may be related to arthritic diseases or stresses resulting from
work or sporting activities. Postural and movement abnormalities will
commonly contribute to these pathologies. The aim of this article is to
outline the common hip conditions and explain the benefit of early
Physiotherapy intervention.
Subjective Examination
Groin pain with referral to the medial aspect of the knee is the
predominant indicator of hip joint pathology. Pain can be experienced in
the buttock region (mainly from the posterior capsule) or lateral aspect of
hip. As lumbar spine and hip problems may often coexist, a differential
diagnosis is required to rule out lumbar spinal or sacroiliac joint
involvement1. A useful differential indicator is that hip joint pain will rarely
refer beyond the knee joint. Pain is usually related to a particular
movement or position of the hip joint or the prolonged maintenance of a
particular posture.
Trauma or repetitive activity may implicate hip pathology. It is important to
discern the mechanism of the traumatic incident along with the
positioning of the hip joint at the time of impact/fall. This information can
then be considered in relation to the physical findings to help form an
accurate diagnosis. A history of congenital defects such as a developmental dysplasia or a previous history of hip epiphyseal
injury is relevant to the development of joint degeneration and movement abnormalities.
Physical examination
Genetic variations in the angle and orientation of the femoral neck can lead to femoral anteversion or retroversion. The
altered alignment of the joint predisposes to excessive wear and tear of the acetabulum or femoral head and may contribute
to the development of altered muscle length i.e. hamstrings or hip flexors and consequently strength imbalances. An
indicator of femoral anteversion is internal rotation of the femur in standing with hyperextension of the knee. An excessive
range of internal rotation will be evident. Conversely a larger range of external rotation is found with femoral retroversion.
A reduction of muscle bulk in the gluteal area indicates poor control of hip extension and/or abduction affecting gait
control. Patients with unilateral hip joint pathology exhibited marked side-to-side differences in the size of gluteus maximus
muscle, which is specific to stage of pathology.2
Pain on muscle testing indicates muscle/ tendon pathology while weakness suggests muscle tearing (providing
neurological compromise has been ruled out). Functional testing such as squatting and full rotation while standing on one
leg are useful indicators of joint dysfunction.
COMMON MUSCULOSKELETAL CONDITIONS
Osteoarthritis (OA) of the hip joint has an estimated prevalence of 5% in those over 60 years with superolateral joint
degeneration most common. The causes can be congenital, traumatic or as a result of a neuromuscular or articular deficit.
In many cases, stiffness after rest may be more troublesome than pain, especially morning stiffness. Physical examination
reveals a pattern of capsular restriction i.e. reduced flexion, rotation and adduction. Gait abnormalities such as a
Trendelenburg gait contribute to the development of lumbar spinal problems and accelerate wear and tear on the articular
surfaces of the hip joint. The RACGP has provided a diagnosis and management algorithm for adults presenting with
suspected hip or knee OA5. Physiotherapy intervention is helpful in the early and middle stages of the disease to relieve pain,
maintain or increase range of motion and improve functional outcomes. Manual therapy aims to restore normal movement
patterns to the joint through joint mobilisation or capsular stretching. A recent review indicated that manual therapy has a
role in the short term management of hip OA but the evidence for weight reduction and range of motion exercises, soft
tissue mobilisation, muscle strengthening and stretching is stronger3,4. Multimodal therapy generally includes manual
therapy consisting of muscle stretching and passive range of movement exercise as an adjunct to an active exercise
component of treatment and it is recommended as4 Physiotherapy treatment for hip OA. Postural advice and gait reeducation also play a role, along with the use of appropriate appliances and aids in more severe cases of OA.
Femoroacetabular impingement (FAI) causes damage to the articular cartilage or labrum. FAI generally occurs as two
forms: Cam and Pincer. The Cam form describes the aspherical relationship between the femoral head and neck. This loss of
roundness contributes to abnormal contact between the head and socket. The Pincer form describes the situation where
the acetabulum has too much coverage of the femoral head. This over-coverage typically exists along the front-top rim of
the acetabulum and results in the labral cartilage being “pinched” between the rim of the socket and the anterior femoral
head-neck junction. The pincer form of the impingement is typically secondary to “retroversion”, a turning back of the socket.
Most of the time, the cam and pincer forms exist together i.e. "mixed impingement". FAI is associated with cartilage damage,
labral tears, early hip arthritis, hyper-mobility, sports hernias, and low back pain. FAI is common in high-level athletes, but also
occurs in active individuals.
Labral tears occur secondary to a traumatic incident or repeated trauma relating to a movement abnormality. Almost 80%
of cases have no known cause. Symptoms include pain/stiffness in hip/groin area, locking, clicking with movement. The
objective examination reveals restricted range of motion with a positive quadrant test (passive flexion, adduction and
compression) and FABER test (flexion, abduction and external rotation). Diagnosis should be confirmed with
MRI/arthroscopy.
Muscle tears around the hip region are a common source of injury generally involving the adductor muscle group and
iliopsoas/ rectus femoris (hip flexors). Pathology is evident when there is pain on resisted contraction of these muscles.
Weakness on testing would infer a disruption of muscle fibres.
Among the sporting community, Gilmore’s groin (Sportsman’s Hernia) involves tearing of the aponeurosis of the external
oblique muscle and/or a tear to the tendon of the Internal Oblique muscle as they converge at the inguinal ligament.
Symptoms are characterised by groin pain, particularly with twisting and turning movements usually radiating to the
adductor muscle region and even the testicles, although it is often difficult for the patient to pinpoint. Diagnosis of Gilmore's
Groin is based on the patient's history and clinical signs, following sporting activity the patient will be stiff and sore; getting
out of bed or a car may be difficult. In the early stages, the person may be able to continue playing their sport, but the
problem usually gets progressively worse.
Trochanteric Bursitisis characterised by pain and swelling on the lateral aspect of the hip over the greater trochanteric
region. Resisted abduction will be painful. Over time the bursa can become thickened which can increase inflammation
causing limited movement and weakened abduction. It can occur when there is infection or bony spurs present, in
conditions such as gout and rheumatoid arthritis.
Hip pain among children covers a wide range of potential causes. Readers are referred to the pGALs assessment format5.
Constant hip pain/ limping in children is often indicative of serious pathology and should be investigated.
How can physiotherapy help?
Physiotherapy can help in the rehabilitation of all the conditions outlined through systematic assessment of the following
factors:
A detailed assessment of the biomechanical factors as outlined above enables the physiotherapist to identify the
predisposing causal factors contributing to degeneration or tissue injury. A specific treatment programme can then be
formulated to target these vulnerabilities, thereby preventing further tissue damage.
Physiotherapy treatment will aid tissue healing and normalise movement patterns by:
•
•
•
Identification and adaptation of structural deficits
Identification and correction of relevant muscle imbalances by means of manual therapy and a
targeted exercise programme
Advice on modification of lifestyle activities including ergonomic assessment and training modification
•
•
Advice on weight reduction programmes
Advice on the use of aids and appliances including orthotic prescription
by Margaret Hanlon MSc, BSc (Hons), MISCP
findaphysio.ie