Hip pain and injury is a complex and fascinating field for us physiotherapists. As medical, anatomical and biomechanical science helps us to understand the entire body better, the hip and its problems are becoming clearer. What we do know is that it’s always a multi-faceted issue to assess. Like all parts of the body, the hip is influenced by all around it.
The hip joint and its surrounding structures form a very strong unit that the body relies upon to transfer energy and force from the foundation of our spine to our lower limb extremities. It’s a ball and socket joint, which allows movement in every direction. The joint and its surrounding muscle strength allows us to effectively transfer the power of our leg to the stability and control of our spine. This creates efficient movement in the ideal world. When this system is faulty, however, the consequence is an injury to the hip joint itself, or to any of the surrounding structures in the said chain of events.
The labrum is a ring of a cartilage type structure that sits around the socket part of the hip joint. It acts to:
- Increase the cushioning and shock absorption of the joint
- Increase the stability of the joint by increasing its surface area
Patients with a labral or cartilage injury will often describe:
- Pain in the groin area
- Limited movement of the hip
- Clicking or locking in the hip joint
Injury to the labrum can be caused by:
- Trauma (including dislocation)
- Repetitive and sustained compression to a specific area of labrum
- Sports or daily activities
- Hip dysplasia (irregular shaping of the joint – genetic)
- Hypermobile joint (excessive flexibility)
- Impingement (compression caused by femur bone)
The key to understanding where to start with treating a labral injury is understanding the patient themselves – knowing the causes in their day-to-day lifestyle, and carrying out an in depth physical assessment. There are then many tests that help confirm a diagnosis of a labral tear for those with hip pain. Tests that compress the joint surface and reproduce the patients symptoms are a very good way to pick up indications of labrum and or cartilage injury.
When we have arrived at the diagnosis of a hip joint labral injury, there are then many factors that need to be corrected. Here, I will discuss these factors and how we go about fixing them:
- Joint restriction/stiffness
Having a tight hip joint will place greater stress on the cartilage and labrum. The best way to improve this is to use distraction techniques to gently open and stretch the joint itself. Massage to the surrounding muscles helps blood flow and can increase mobility.
- Muscle tightness
Key muscles that pose a problem for the hip joint are the hip flexors, the groin muscles (adductors), the deep hip rotators (piriformis) and the tensor fascia latae (TFL). Trigger point therapy, targeted stretches and self release, active release techniques, sports massage and dry needling are all successful when dealing with muscle tightness.
- Pelvis/lumbar spine
Any alteration to normal biomechanics in these areas will affect the hip joint. Both structures have many muscles that cross from one to the other, thus directly contributing to the way that the hip moves. A Pelvis rotation/twist is best fixed with manual mobilisation and manipulation, followed by core and muscle strengthening. Lumbar spine stiffness will also increase the demands on the hip, so stretches can really help.
- Weak core
A weak core means poor stability. Imagine running on sand as compared to concrete. When running on sand you have no stability – every muscle has to work harder, and your speed and power drop as there’s no solid foundation from which to move from. Studies have shown that weak core muscles are a common factor in patients with hip pain, often related to previous injuries or misfiring muscles. Without these muscles helping to stabilise the area, the hip joint has to cope with considerably more stress. Specific exercises to target the transverse abdominus, the mulitifdus and the pelvic floor are often recommended by physios.
- Weak glutes
The glutes are a fascinating group of muscles, comprising of three muscles in the buttock area. They serve to create power when we walk and run. They create stability at the same time, and prevent a drop of the opposite hip when walking and running. Single leg squat and running assessments will pick up any issues with weak glutes. When combined with core strengthening, the hip joint and its labrum/cartilage are only going to be healthier from all of the the hard work.
- Flat feet and ankle stiffness
People with fallen arches are more likely to have hip pain. As the foot rolls in, the hip joint twists inwards slightly, compressing the front of the joint. Added up over the thousands of steps we take each day, an abrasive stress is only going to wear away at the labrum.
- Posture – Sitting and standing
Sitting compresses the front of the hip labrum and cartilage, and when combined with crossing your legs, a dangerous situation can arise. Fixing any issues ergonomically will help this – for example, if your chair is too low then the hip joint will be more flexed, and this will need to be corrected. Standing with all of your weight shifted to one side will jam your hip joint. This coincides with muscles weakness in your core and glutes, and is something that always needs fixing. Too often, this is a problem with young mums who only hold and carry their child on one hip.
One of the most crucial elements to treating people successfully is understanding the way that the patient moves. If we don’t solve the potentially harmful movement patterns that a patient has, then we won’t ever be truly successful with our treatment. Running assessments, golf swing analysis and other sports-specific tests are the best way to understand and correct movement pattern dysfunctions.
Now, it’s also important to mention that the injury that does not always heal with conservative treatment. Some tears and degenerative injuries in the hip joint have a limited ability to heal due to limited blood supply. This may indicate the need to consult with an orthopaedic surgeon to understand potential surgery options. Avoiding this need for surgery is the aim of all physiotherapy treatment programs.
Hip joint pain is a debilitating and complex injury, and patients often leave it too long to have it fixed. For treatment to be more successful, it needs to be early on in the process. In the end, I implore patients to listen to their body more. You need to trust what your body is telling you before it’s too late and the full injury process has set in.
Problems with Hip Pain?
Thanks for reading!
This post has been written by PhysioActive physiotherapist Joel Bates.
Thoughts or questions?