Posts in Hip
Physical Therapy Reduces Need for Total Hip Replacement
physical-therapy-hip-pain-arthritis

Over 200,000 Americans undergo a total hip replacement often as a result of severe hip osteoarthritis.  Patients who enter the surgery in a weakened, less functional state have worse outcomes up to 2 years post operatively compared to their higher functioning peers (Fortin et al. 1999, 2002).  This is concerning because the most rapid recovery after surgery occurs in the first 3 months with slower recovery up to 1 year.  A patient with more difficulty entering surgery would have limited success in this crucial window in their recovery.  Conversely, pre operative Physical Therapy for patients with limited flexibility, strength, balance, and endurance can improve surgical outcomes, but similar to research in knee osteoarthritis may delay or prevent the need for the surgery.  

A recent study was conducted to determine the long term impact of PT interventions on patients with hip osteoarthritis (Svege et al. Ann Rheum Dis. 2015).  Patients were randomized to either an education or PT group and followed up to 6 years after the treatment.  The authors reported the average time to a total hip replacement was 5 and a half years in the Physical Therapy group compared to 3 and a half years in the education group.  In addition, twice as many patients in the Physical Therapy group did not require surgery reducing the need for surgery by 44%.  

This evidence adds to our knowledge on the beneficial effects of Physical Therapy on patients with hip osteoarthritis.  Patients with hip pain are advised to see a Physical Therapist to postpone or prevent the need for a total hip replacement. 

Lateral Hip Pain and Bursitis

Patients with outer hip, lateral, pain have previously been diagnosed with trochanteric bursitis indicating the fluid filled sack between our hip muscle tendons and our thigh bone is to blame for their symptoms.  In addition the -itis ending in the diagnosis leads us to believe there is an inflammatory process taking place in the hip.   Interventions designed to combat inflammation where previously utilized in an attempt to reduce pain and improve function.  Based on the recent research experts have moved toward a more accurate diagnoses for symptoms in the lateral hip which is changing our understanding of the pathology and treatment interventions for this common condition.  

boulder physical therapy lateral hip pain bursitis

Experts are currently moving away from the diagnosis bursitis due to the lack of confirming findings on diagnostic imaging.  Bird et al. reported only 8% of patients with lateral hip pain had bursitis on ultrasound imaging (Arthritis and Rheum. 2001).  A recent study by Long et al. found 80% of close to 800 patients with lateral hip pain did not show any signs of bursitis.  Conversely these imaging studies, including MRI, are finding more chronic, degenerative (scar tissue) changes in the tendons on the gluteus medius and minimus tendons as well as the IT band.  These changes explain the limitations of interventions designed to treat inflammation in these patients.  

The diagnosis Greater Trochanteric Pain Syndrome (GTPS) is now being utilized to more accurately describe these chronic changes among patients with lateral hip pain.  GTPS accounts for a small amount of sports injuries but has its' highest incidence among individuals aged 40-60 years old (Mulligan et al. 2014).  In our Physical Therapy practice we commonly see this condition among individuals with a prior history of low back pain and IT band pain.  These patients often demonstrate weakness in their hip musculature leading to muscle imbalances across the lower quarter.  The degenerative changes in the tendon represent a decrease in the tendon's ability to tolerate loading in movement and athletic events.  Interventions should focus on correcting hip muscle imbalances and poor movement patterns which perpetuate this condition.   When appropriate, progressive resistance exercises should be implemented to improve these tissues' ability to tolerate stress and help remodel the tendon.

To learn more about how to accurately diagnose and treat your lateral hip pain contact your local Boulder Physical Therapists at Mend.

Hip Pain and the Role of Diagnostic Imaging

Often in Physical Therapy we are asked if an image would help in our diagnosis or treatment of a patient's symptoms.  The answer is very dependent on the individual patient's case but in most cases imaging has not been shown to improve outcomes.  In prior posts we have discussed the strengths and limitations of diagnostic imaging such as MRI or x rays for musculoskeletal pain.  One of the main limitations of these tests is the presence of both false negatives, the absence of pathology in those who have symptoms, or the more risky false positives, the presence of pathology in those who do not have symptoms.  As our technology has improved we are able to view body structures in greater detail leading to "positive" findings even in asymptomatic people.  These false positives may lead to unnecessary tests, medications, or procedures if they are not balanced by thorough clinical exam.  

Recently researchers in the British Medical Journal published a study on the relationship between hip pain and x ray evidence of hip arthritis (OA) (Kim et al. 2015).  The authors performed x rays on subjects and then interviewed these individuals for the presence of pain in the hip, groin, or low back.  In one cohort of the study of >900 participants only 16% of painful hips showed evidence of OA (false negative) and only 21% of hips with the presence of OA were painful (false positive).  Similarly, in a second cohort of >4300 patients the authors found only 9% of frequently painful hips showed signs of OA and 24% of hips with OA were painful.  

The authors concluded that hip pain was not present in many hips with OA and many hips with pain did not not show signs of hip OA.  The authors recommend utilization of a strong clinical examination prior to diagnosis based on diagnostic imaging alone.  Visit your local Physical Therapist to assist in your evaluation and treatment of hip pain.

Hip Osteoarthritis and Physical Therapy Treatment
hip arthritis, physical therapy treatment, boulder
hip arthritis, x ray, boulder physical therapy

Hip Osteoarthritis Background

Hip Osteoarthritis (OA) is considered one of the most serious musculoskeletal problems secondary to its impact on patients’ pain and disability, as well as, the economic impact on our healthcare system.

20% of the aging population will experience hip OA and the condition is a predictor of current and future func- tional disability and mortality(1,2).

Only 20% of patients with hip OA on x ray testing will end up having a total hip replacement 11-28 years after diag- nosis. Quality conservative care is crucial for this population(3). 

Physical Therapy Interventions

hip arthritis, manual physical therapy, boulder

Clinical practice guidelines recommend the use of educa- tion, weight reduction, gait and balance training, exercise size, and manual therapy in the management of patients with hip OA(4).

Manual therapy interventions including joint mobilizations/ manipulation reduce pain, improve ROM and reduce disability in patients who do not have severe, end stage hip OA(4). 

Physical Therapy Evidence for Hip Osteoarthritis

81% of patients reported reduced pain, disability, and a high level of perceived recovery following a treatment plan of manual therapy compared to exercise alone(5).

Pinto et al. reported manual therapy and exercise were more clinically and cost effective than usual care in an evaluation of treatments for patients with hip OA(8).

Exercise interventions including flexibility/range of motion exercise, strengthening, and aerobic exercise are supported for their impact on reduc- ing pain and disability for patients suffering from hip OA(4). 

hip strengthening, arthritis, boulder physical therapy

When to seek Physical Therapy care

Clinical clusters of Hip OA include one of the following(6)

All 3 findings                                                                                                                                            

Pain in hip

<115 degrees hip flexion

<15 degrees hip internal rotation

All 3 findings

Pain with hip internal rotation

<60 minutes of morning stiffness

>50 years of age

Sutlive et al. reported a cluster of findings including the following demonstrated a (+)LR of 24.3 or 5.2 for 4/5 or 3/5 findings respectively(7).

Squatting as aggravating factor

(+) active hip flexion causing lateral hip pain

(+) scour test causing lateral hip or groin pain

Active hip extension causes hip pain

Passive internal rotation range of motion <25 degrees 

References

1. Odding, E. et al. Determinants of locomotor disability in people aged 55 years and over: the Rotterdam Study. Eur J Epidemiol. 2001. 17(11):1033-1041

2. Nuesch, E et al. All cause and disease specific mortality in patients with knee and hip osteoarthritis: population based cohort study. BMJ. 2011.

3. Franklin, J. et al. Natural history of hip OA: A retrospective cohort study with 11-28 years of follow up. Arthritis Care Res. 2011. 63(5):689-95

4. Cibulka, M. et al. Hip Pain and Mobility Deficits – Hip Osteoarthritis. Clinical practice guidelines. JOSPT. 2009. 39(4):A1-A25.

5. Hoeksma H et al. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a RCT. Arthrtis Rheum. 2004. 51:722-729.

6. Altman R, Alarcon G, Appelrouth D, et al. The American College of Rheumatol- ogy criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum. 1991;34:505-514.

7. Sutlive, T. et al. Development of a clinical prediction rule for the diagnosis of hip OA in individuals with unilateral hip pain. J Orthop Sports Phys Ther 2008;38(9):542-550.

8. Pinto, D. et al. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee. Economic evaluation alongside a RCT. Osteoarthritis and cartilage. 2013. 

Hip Pain associated with Femoral Acetabular Impingement and Labral Tears
hip pain, sports injury, impingement, and labral tears

Hip Pain associated with Impingement and Labral Tears

hip pain, femoral acetabular impingement
femoral acetabular impingement, bone morphology, pain, injury

Femoral Acetabular Impingement (FAI) is defined as the mechanical abutment of the femoral head against the acetabulum1. This contact is either structural (cam or pincer lesion), functional or a combination of both and results in pain, loss of motion, and disability.

Researchers have questioned if the findings noted on x-ray are a normal morphological changes based on anatomy and biomechanics or a structural pathology(3).

These structural changes are apparent in asymptom- atic individuals and there are currently no randomized controlled trials showing they lead to early OA or hip surgery(2).

In a study of over 2000 asymptomatic hips authors noted labral and FAI bone changes in 68% and 67%, respectively. The prevalence of pathology consistent with FAI was higher in asymptomatic athletes(5). Pathology in asymptomatic hips also appears to increase with age(6).

Authors note an 18 fold increase in surgeries from 1999 to 2009 and a 365% increase in surgery between 2004 and 2009 among 20-39 year olds alone(4). This rapid increase in surgery is thought to be due in part to an increase in MRI being performed in this population.

Physical Therapy Solutions for Hip Pain

Conservative treatments are the first line of treatment for patients with anterior hip and groin pain resulting from labral tears or FAI. Interventions include activity modification, education, manual therapy (joint mobilization/ manipulation, soft tissue mobilization, and dry needling), self hip mobilizations, and exercise (stretching, strengthening, balance, and motor control) interventions.

Experts suggest a 8-12 week course of conservative care may improve decision making for possible surgical referral(3).

Ayeri et al. demonstrated a negative response to an injection predicts a negative outcome following surgery more than a positive response for a positive outcome after surgery(8). 

hip manual physical therapy, hip pain, sports injury

Physical Therapy Evidence for Treating Hip Pain and Injuries

Evidence for the conservative treatment of FAI lesions is currently at a case series level of research for both conservative and surgical treatments. To date no randomized controlled trials or long term data exist on surgical outcomes.

Kemp et al. documented poor outcomes for patients undergoing FAI surgery with greater chondral damage and those over age 40(9).

Hunt et al. found a multimodal treatment approach consisting of manual therapy, exercise, and education reduced lower quar- ter impairments and improved function at both short and long term outcomes(7).

In our experience at Mend, athletes and patients with a diagnosis of labral tears or FAI are able to return to sport following a treatment plan involving manual therapy, exercise, biome- chanics evaluation and modifications (ie gait analysis), and education. 

hip pain and injury strengthening exercises

When to seek Physical Therapy for Hip Pain and Injury

Athletes and patients with anterior hip and groin pain, loss of hip range of motion, and disability should be referred to Physical Therapy for conservative management.

Pain mainly in the groin (sensitivity .96-1.0) and a subjective report of hip/groin pain with clicking, locking, and giving way (sensitivity 1.0, specificity .85) may assist in the diagnosis of an acetabular labral tear(10,11). 

References

1. Ganz R, Parvizi J, Beck M, et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003(417):112–20.

2. Collins JA, Ward JP, Youm T. Is prophylactic surgery for femoroacetabular impingement indicated? A systematic review. Am J Sports Med 2014;42:3009–15.

3. Reiman, M. Femoracetabular Impingement Surgery: Are we moving too fast and too far beyond the evidence? Br J Sp Med. 2015. 0:1-6.

4. Montgomery SR, Ngo SS, Hobson T, et al. Trends and demographics in hip arthroscopy in the United States. Arthroscopy 2013;29:661–5.

5. Frank, J. et al. Prevalence of FAI imaging findings in asymptomatic volunteers. A systematic review. Arthroscopy. 2015:1-6.

6. Nardo, L. et al. FAI: Prevalent and Often Asymptomatic in Older Men: The Osteoporotic in Men Study. Clin Orthop Relat Res. 2015

7. Hunt D, Prather H, Harris Hayes M, et al. Clinical outcomes analysis of conservative and surgical treatment of patients with clinical indications of prearthritic, intra-articular hip disorders. Pm R 2012;4:479–87.

8. Ayeni OR, Farrokhyar F, Crouch S, et al. Pre-operative intra-articular hip injection as a predictor of short-term outcome following arthroscopic management of femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc 2014;22:801–5.

9. Kemp JL, Collins NJ, Makdissi M, et al. Hip arthroscopy for intra-articular pathology: a systematic review of outcomes with and without femoral osteoplasty. Br J Sports Med 2012;46:632–43.

10. Keeney JA, Peelle MW, Jackson J, et al. Magnetic resonance arthrography versusarthroscopy in the evaluation of articular hip pathology. Clin Orthop Relat Res 58 2004;429:163–9.

11. Burnett RS, Della Rocca GJ, Prather H, et al. Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am 2006;88:1448–57.