Posts tagged hip pain
Dry Needling Improves Pain, Mobility, and Function In Patients With Hip Arthritis
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Hip arthritis is a painful condition causing pain, loss of range of motion, and lost function in many middle to older aged adults. The pain from hip arthritis is multifactorial in nature arising from the cartilage and joint surfaces as well as the surrounding soft tissues. Physical Therapy consisting of manual therapy and strength training remains the first line treatment for patients with hip arthritis. High level exercise has previously been shown to preserve the patient’s native hip delaying the need for a total joint replacement. Previous research has documented the benefits of joint mobilization and manipulation in patients with hip arthritis, but recent research has highlighted the benefits of dry needling by Physical Therapists in this condition.

Ceballos-Laita and colleagues conducted a double blind, randomized controlled trial on the effectiveness of dry needling in patients with hip arthritis (Musculoskelet Sci Pract. 2019). 30 patients were randomized to either dry needling or a sham needling group for 3 treatment sessions. Patients’ pain, function (gait and strength), and range of motion was assessed at baseline at at the conclusion of the treatment sessions. Authors found significant improvements in pain, range of motion, and function after the dry needling treatment compared to the sham group. Interestingly, the sham group reported increased pain and decreased hip range of motion at the conclusion of the trial. This study indicates dry needling may be included in a Physical Therapy treatment plan for patients with hip arthritis to reduce pain and facilitate a rapid transition to an exercise program.

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Only 1/3 Of Patients Are Satisfied With Activity Level Following Surgery For Hip Impingement
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Hip impingement (FAI) is one of the fastest growing orthopedic surgeries, but much of this growth has outpaced our current understanding of this condition. A key question involves the additional bone development (cam and pincer lesions) found among athletes. Many of these athletes remain asymptomatic despite having positive findings of impingement on x ray and other imaging techniques. Other athletes with FAI who are symptomatic often return to sport and high function after undergoing Physical Therapy indicating some individuals are able to compensate and adapt for these structural changes or they may be a natural response to the sport itself.

Previous research has found equivocal long term outcomes between Physical Therapy and surgery for hip impingement. This data indicates a significant duration (8-12 weeks) of Physical Therapy should be attempted before surgical interventions. The majority of athletes undergoing hip impingement surgery will return to sport around 6-10 months post surgery, but many will be unable to return to their pre injury levels of activity. Prior studies have found only half are able to return to their previous sports and 1 in 5 will be able to return to the same sport with the same level of performance. A recent study sought to understand how these individuals function 6-10 months after surgery.

The Orthopedic Journal of Sports Medicine followed 33 patients who underwent hip arthroscopy for conditions involving hip impingement (Worner et al. 2019). On average, patients were reassessed at 8 months post op and their subjective history and objective testing were compared to their age matched peers. Authors reported decreased subjective function and ability to return to sport in the surgical group. Specifically, 46% and 18% were able to return the same sport at a lower or similar level, respectively. Consistent with prior research these individuals regained strength and range of motion after post operative Physical Therapy except continued to experience decreased hip flexion strength and range of motion compared to their peers.

This study adds to our existing knowledge on the recovery following hip arthroscopy for hip impingement. Despite being cleared to return to sport many athletes will require additional recovery time to regain participation in sporting activities.

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Majority of Patients With Hip Impingement Did Not Receive Physical Therapy Prior To Surgery
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Hip impingement or femoroacetabular impingement (FAI) is common hip condition causing pain in the front of the hip and groin. This condition has received considerable attention in the medical research and our clinical practice because of the sky rocketing rates of advanced imaging including MRI and surgical procedures to “correct” the condition. Of greatest concern are the high rates of hip impingement and labral tears found on imaging in asymptomatic (pain free) individuals. Thus, are the structural changes associated with FAI natural adaptations to activity or do they require surgical intervention? The lack of a clear cause and effect between structural FAI and a patient’s symptoms supports the utilization of conservative interventions including Physical Therapy prior to any surgical intervention. Consistent with other musculoskeletal conditions, one of the main indications for surgery remains failure of conservative care, but a new research study reported the majority of patients with FAI did not receive Physical Therapy before surgical interventions.

In the Journal of Sports and Orthopedic Physical Therapy authors reported on health care utilization of patients undergoing hip arthroscopy between 2004 and 2013 (Young et al. 2019). They reviewed the charts of 1870 participants who underwent this procedure to determine what interventions they were offered prior to their surgery. Surprisingly, 60% (n=1106) did not receive any Physical Therapy prior to surgery and for those who did receive Physical Therapy they averaged only 2 visits, well below the standard of care for this condition. Further, only 12% of patients undergoing PT received 6 or more visits including exercise. Surgery is reserved for patients with persistent functional limitations (disability) not pathology (hip impingement on imaging), but without an evidence based course of Physical Therapy surgical decision making will be remain unclear.

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Optimizing Glut Activation During The Crab Walk
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Strengthening the muscles of the hip, gluts, is a key component of rehabilitation for patients with low back pain, hip pain, and knee pain. These muscles help to optimize movement in the lower quarter improving joint mechanics and force distribution during life and recreational activities. In our Facebook posts, we have shown videos on optimizing the firing in the muscles on the back and side of the hips. These videos detail beginning, intermediate, and advanced exercises for each muscle group. One commonly utilized exercise is the crab walk which incorporates a lateral side stepping movement against a resistance band. A new research article highlights how placement of the band can optimize recruitment of the glut muscles.

Lewis and colleagues analyzed the activation of the glut muscles during a crab walk exercise using different elastic band positions (J Athletic Training. 2019). 22 healthy adults were asked to side step with the elastic band around the knees, ankles, and feet. During each 3 of the conditions, researchers analyzed EMG activity from the hip muscles including the TFL, gluteus medius, and gluteius maximus. As expected, increased glut work was found when the band was moved from the knees to the ankles lengthening the lever. Interestingly, placing the band around the feet increased the glut work without increasing the contribution from the TFL (often a muscle we try to utilize less during exercise). Thus, placing the band around the feet may be an optimal position to recruit the hip with less contributing from compensatory muscles.

Physical Therapy Reduces Healthcare Costs and Opioid Utilization After Hip Surgery
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Arthroscopic hip surgery rates have dramatically increased in the last decade due in part to increased MRI imaging.  MRIs are very sensitive, but lack specificity in many musculoskeletal disorders with high rates of false positives among asymptomatic populations.  Hip pathologies such as impingement (cam or pincer) and labral tears can be found in up to 68% of patients without hip pain.  As we described in our previous blog posts, many patients with these pathologies are able to improve pain and function with Physical Therapy alone.  Further, authors report no differences in long term outcomes between surgery and Physical Therapy.  A new study highlights the importance of post operative Physical Therapy in patients who do not respond to conservative treatments.  

Rhon and colleagues followed patients who underwent hip arthroscopic surgery between 2004 and 2013 to determine their outcomes and healthcare utilization (Physical Therapy. 2018).  The authors reported on 1870 patients of which 83% received Physical Therapy alone, 72% received opioid medication, and 56% received both Physical Therapy and opioid medication.  Authors reported a $5000 savings on healthcare expenditure, a reduction in subsequent hip surgeries, and opiod utilization among patients receiving Physical Therapy first.  Not surprisingly, patients receiving opioids first utilization more medication, over a longer period of time compared to patients receiving Physical Therapy.

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Low Rates of Arthritis Found Among Marathon Runners
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Similar to Sasquatch and the Loch Ness Monster science may also be putting another myth to rest.  In our previous posts, we have written on the lack of data supporting the idea running leads to wear and tear or arthritis.  In fact, some research has shown running may have a protective effect on joints with runners having significantly less arthritis than their sedentary peers.  Until now there has not been a study which examined the link between running and arthritis among marathon runners.

Ponzio and colleagues examined 675 marathon runners (at least 5 marathon races) subjectively for complaints of pain, lost training or race time, and arthritic diagnoses (Journal of Bone and Joint Surgery, 2018).  The runners in the trial ran an average of 36 miles per week with an average running experience of 19 years.  About 1 in 2 marathoners reported hip or knee pain, but the overall prevalence of arthritis was 9% well below the national average of 18% even when controlled for age, sex, body mass index and activity level.  The authors concluded "there was no significant risk associated with running duration, intensity, mileage, or the number of marathons completed."  The authors did note age, family history, and surgical history independently predicted an increased risk for arthritis among the 9% with arthritis.  

This study adds to the literature refuting the link between running and arthritis.