Physical Therapy Series: Hip Pain
Hip pain is a common reason to visit the orthopedic clinic. In this blog we will discuss the most common reasons for hip pain in middle age, the importance of physical therapy in treating hip pain along with some exercises, and my own experience with hip pain.
When patients come into the orthopedic office complaining of hip pain it is important to localize the exact area of pain as there are many structures in the hip region that could be the source. Low back pain is commonly mistaken for hip pain and patients will often describe pain along the belt line of their back and refer to this as the hip. While the upper portion of some of the hip bones are in this area, the actual hip joint is deep in the groin. If this is the case, and you are having low back pain, you may consider referring to “Physical Therapy Series: Low Back Pain”.
Another common culprit of “hip” pain is trochanteric bursitis/gluteal tendinitis. In the outer area of the hip where most people would place their hands on the hip is a bony protrusion of the thigh bone called the greater trochanter. The structures overlying the greater trochanter (bursal sac, gluteal tendons) can become inflamed and painful. Bursitis will be point tender on the bone and will improve with medication, an injection, or therapy. Gluteal tendinopathy is inflammation or partial tears of the gluteal tendons that attach to the great trochanter. Therapy is the first line of treatment for these injuries. Surgery is rare and only considered if conservative measures fail.
Pain in the front of the hip in the groin could be arthritis. Arthritis will often present with a decreased range of motion and can be confirmed with an x-ray. Physical therapy is critical to improving mild and moderate arthritis pain. Severe arthritis would likely require a hip replacement surgery. Hip flexor tendinitis is another common cause of anterior hip pain. The motion and the x-ray will often be normal but the exam will confirm the diagnosis.
Therapy is the first line of treatment and surgery is rare. The labrum is the thick cartilage ring around the hip joint socket. Large tears may benefit from surgery but the majority of tears in middle aged patients are small degenerative tears that will improve with therapy. When someone complains of a pulled groin they are referring to an injury of the inner thigh muscles. Anterior hip flexors, posterior hamstring attachments, and the groin muscles can be strained, partially torn, or completely torn. It is unusual to have surgery on the tendons around the hip even if completely torn in middle age. You may hear about these surgeries in elite athletes but your surgeon will likely consider conservative care with physical therapy if possible. Fractured and dislocated hips are major injuries that usually present to the emergency room or trauma centers. Patients with snapping hips may believe their hip is dislocating. However, the deep shape of the hip socket makes a dislocation unlikely unless there is a forceful trauma. It is more likely the snapping is caused by a rubbing tendon which can be treated with therapy.
If you read the blogs on physical therapy for the back and the shoulder you will see I mentioned some evolutionary biology and some ideas about why these joints are prone to injury. I could not find anything referring to the human hip which must mean the evolutionary biologists consider the hip to be perfect with no design flaws. Instead, I found a video explaining the anatomical difference between women's hips and men’s hips. Women’s pelvises are wider and shorter which enables them to deliver babies with big heads. Fun Fact- This results in some angles in the pelvis and femurs that are different from men and ultimately leads to women swaying when they walk. The wider hips do not seem to cause an increase in hip injuries but it is linked to an increase in knee injuries.
Just like in the other joints, sitting too much is bad for our hips. It shortens and weakens the hip flexors making them prone to injury. Another common reason for hip pain is bad posture.
Anterior pelvic tilt is the result of bad posture and worsened by sitting. It is caused by weak muscles rather than genetics. If your entire family has bad posture then your whole family has a muscle imbalance. You did not inherit their posture but rather their bad habits. The anterior pelvic tilt results in short and weak hip flexors and a stiff back. This is one of the reasons back pain and hip pain often show up together. It is also the reason many hip and back programs address both body parts. Many patients will falsely believe that they can’t have weak hips because they are weightlifters or have occupations that require heavy lifting. In reality most lifting exercises do not strengthen the hip flexors in a lengthened position. The video illustrates how to turn on these dormant hip muscles. Whether or not your anterior tilt is totally corrected, these exercises will help improve your pain.
In the previous therapy blogs I discussed the 3 phases of physical therapy. The “prehab” phase, the “injured phase” and the “recovery phase”. Whereas almost everyone will have low back pain or shoulder pain in their life not everyone will get hip pain. For this reason exercises in the “prehab” phase may not be quite as critical unless you are determined to bulletproof your body. On the other hand if you have some tightness you will be prone to injury and should consider some preventive exercises. Many of the following programs are good if you have a mild injury. For more severe problems you should see your orthopedist. In the “recovered phase”, you should continue these exercises a few times a week. Once injured your hip has established itself as a problem area and these exercises will help control the issue.
Mild hip bursitis will often respond to therapy exercises. An anti-inflammatory medication or supplement and ice can be helpful. An injection often resolves the issue. If you get relief from an injection you should consider continuing some simple exercises to keep the problem from returning.
This video explains how to differentiate the two most common reasons for lateral hip pain. The exercises start at 3:10 and include:
1. Foam roll
2. Advice on how to sleep and prevent worsening the strain
3.Hip abduction exercises.( you can do these without the band)
4. Side Plank and Hip abduction
5. Single leg fire hydrant- you can do these without the band . These are challenging and I would recommend for athletes only.
For those with anterior hip pain and hip flexor tightness.
There is an explanation how to confirm your hip flexor tightness and the exercises start at 5:30.
Massage Hip Flexors with a tennis ball
Tall Kneeling stretch
Tall Kneeling stretch with a chair- Hip flexors and quadriceps
Walking lunge
And two videos for hip pain or tight hips in general. Remember a stiff or weak joint is a painful joint. These exercises can be helpful with tendon issues, degenerative labral tears, and mild to moderate arthritis. If you have arthritis doing rehab exercises may help you avoid surgery or at least delay surgery. If you ultimately need surgery, having strong flexible hips will make your recovery much easier.
Gluteal stretch
Piriformis stretch
Hamstring stretch
Hip abductor stretch
Hip flexor stretch
Hip bridge
Clam shell
Fire Hydrant
Hip abduction
Hip flexion
A unique way to test your hip and lower extremity mobility is to do a deep squat in which your feet and heels remain flat on the ground. The ability to do this will test your functional range of motion. If you have a significant injury you can consider skipping this but for everyone else it is a fun challenge.
My own hip pain has gradually increased with age. If you have read the blogs on physical therapy for the back and shoulder I do not want you to get the impression I am falling apart. I have never had disabling hip pain but I have had nagging anterior hip pain for a few years off and on. The reason for this is I have an anterior pelvic tilt ( which I discussed above) due to bad posture. I have no idea when this started. This results in tight or weak hip flexors. I have several active friends my age with the same problem. A few years ago I started doing exercises and resolved my hip pain. An example of not practicing what I preach, I stop doing the hip exercises when the pain goes away and the pain always comes back. It never hurts when I play sports but can be painful if I stand for long periods or walk on flat ground for several miles after playing sports. The solution is simple and works every time: Do the exercises 3 times a week.
I have mentioned previously that sugar and processed foods increase chronic inflammation in the body. Some people can tolerate this level of inflammation without joint pain. As we age we develop more wear and tear of the joints and fewer and fewer people can tolerate the chronic inflammation that will settle in problem joints. My right hip is my personal fire alarm. I used to eat whatever I wanted from Thanksgiving to New Year’s Day and by the end of this period my joints would hurt, but my right hip was the worst. If I eat healthy, I can tolerate sugar and processed food a few times a week. I run into problems when it is several days in a row. For instance, this Thanksgiving we had the standard celebration food from Wednesday through Sunday. Pies, cookies, breads, coffee cake, and stuffing at every meal with plenty of leftovers. By Monday my hip was reminding me I could not eat like that any longer. Now another holiday approaches. I will try to stick with my hip exercises and limit the foods that set off my inflammation. Wish me luck.
In our struggles to be healthy we all have our personal kryptonite. One of mine is stretching. I go through periods where I stretch every morning for 5-10 minutes before I jump in the shower. This always improves my hip pain and overall stiffness, but I always slack off once the pain improves. I could stretch after my workout but I often just lie on my back and even nap, postponing the quick stretch that never comes. I have recently found a solution. I go to Stretch Zone once a week for a 30 minute stretch session. I relax and let the practitioner stretch me. It is similar to how trainers stretch the elite athletes. I understand I could join a yoga class or do a home yoga/stretch program and get a good result but Stretch Zone only requires me to have the willpower to drive there. My preliminary results are great. My pain, stiffness, and workout performance have all improved. I will certainly add this to my toolbox moving forward.