Hip Pain

Don’t Sit on Your Wallet

Think about what bone you sit on. It’s called the Ischial Tuberosity. It is at the base of your pelvis which provides the base for your spine to fit in. You can imagine if one side is pushed higher the effect it has on your pelvic alignment and spinal alignment. As your pelvis and spine are deformed with activities such as sitting on a wallet, ligaments holding your pelvis and spine together stretch. Do it long enough and the laxity of these ligaments can increase permanently, leading to chronic spinal or pelvic misalignment and instability.

Symptoms caused by this could be sciatic pain, glut and or lower back pain. Additionally this can effect the ability to exercise. Leading to a truckload of problems. Sitting-on-a-wallet

With the current use of cards that you tap, thick wallets should be a thing of the past. However even a thin wallet used consistently over time will create enough disturbance in the bones and joints of your lower back and pelvis.

Clinically we see pelvic instability a lot. Wheather it be postnatally, injury related or degeneratively. It can be a real tough problem to fix with lots of work for the patient to do themselves. So the best medicine in this case is definitely prevention.



Hip Pain and the Dorsa Vi


One of the common issues we see in the clinic, especially amongst the running population, is poor hip control and strength.    This type of hip dysfunction often leads to a variety of injuries such as anterior knee pain, hip pain and low back pain.  As clinicians we are able to subjectively view someone’s running gait and determine where their deficiencies are.   This however is purely subjective and doesn’t give us concrete data on how bad the control actually is and is hard to measure positive change effectively.

This has now become an issue of the past with recent technological developments.     Using Vi Move, which is a system using sensors, we are now able to quantify hip stability and strength issues.   One of the ways in which we do this is by hooking a patient up to 2 sensors on the shin bone and measuring knee collapse in anything from single leg squat to box jumps.   It’s a great objective measure that we can then rehab and re-measure after following a strength program.

Further to these sensor placements we can also put them on the low back and pelvis and test single leg hurdle step and a lunge to see how the hip is affecting low back and pelvis alignment.   The benefit of these sensor placements is you can then look at it with real time training.   This will allow you to watch the sensors on the screen and give you real time feedback on how to move properly and engage better hip control.

Gluteal Tendinopathy

Lateral Hip Pain – Don’t Stretch It!

Did you know 1 in 4 women over the age of 50 suffer from gluteal tendinopathy at some point in their life?

And women are 4 times more likely to suffer than men?

What is Gluteal Tendinopathy?

The most common cause of lateral (outer) hip pain is change within the gluteal tendons (tendinopathy) due to persistent overload. This commonly results in secondary inflammation of a fluid filled sac known as a ‘bursa’, due to compression or friction of the Illiotibial band (ITB). It is now understood that gluteal tendinopathy is the primary driver of pain, rather than inflammation of the bursa.


Gluteal tendinopathy can be caused by:

  • A recent increase in exercise (walking, running, step machines) especially in females 40-60 years
  • Prolonged sitting, or sitting with legs crossed
  • Compression forces due to side-lying
  • Standing with more weight on one leg, such as carrying a child on your hip
  • Decreased muscle strength of the gluteal muscles resulting in a positive ‘Trendelenburg’ sign



A positive Trendelenburg sign results when a drop of hip height on the opposite side to the weight bearing leg is observed.

Why are women more susceptible than men?

Women are more likely to suffer from gluteal tendinopathy due to decreased gluteal muscle tone (especially post menopause), and wider hips also influence the amount of compression.

Treatment – Should we stretch our glutes?

Compression is thought to be a key factor in tendinopathy and placing your glutes on stretch will increase compression on the gluteal tendons, therefore, stretching is not recommended. Treatment should involve correcting postural abnormalities (you may not even know that you’re aggravating your pain) and increasing pelvic stability through tailored strengthening exercises by your physio or clinical pilates instructor.

Screen Shot 2015-11-11 at 9.42.25 am

Remember.. DON’T stretch it and if you’re unsure… Come and see us at either our Sydney CBD physiotherapy clinics or our new Chatswood Physiotherapy clinic.

Hip Flexor Strain

Hip flexors and runners: the misunderstood muscles

Spring is here and it is time to dust of those runners and hit the bitumen. What better way to kick start your fitness routine than with some lunch time runs, and for the ambitious lot, half or full marathons.

After your quick Merv Hughs warm ups and your Rocky Balboa bounce to get the body going  you quickly start a light canter; have you experienced that dreaded tight feel in your hip flexors, perpetual fear of pulling a muscle, pain as you hit the hot bitumen as you glide to a stop with as much grace as an elephant on skates?

Then as much as you demonstrate your repertoire of stretches and releases on the sore and affected areas nothing helps. Any relief you get froiliopsoa_3m the so called advanced stretches you learned from hot yoga only give you point in time static relief. When you again start your canter it all goes wrong again!!!!

No its not time to throw those shoes away or think about leg replacements…..it’s just your hip flexors and they need some help.

So what really causes hip flexor tightness and pain during running?

We often instinctively seek treatment to the area that we feel discomfort, and conclude that the area is the source of the problem.

Problem 1: I feel tight in my hip flexors during a run.

Solution: Stretch and or Release

Problem 2: I have pain and I think I pulled a muscle in my hip flexor

Solution: Treat muscle with rest and/or ice

Now in most cases the above solution may help, in a lot of situations running will aggravate the same injury.

“Fool me once, shame on you, fool me twice, shame on me”

We need to change the perspective and look at running in a more holistic manner. Running requires our whole body system to be working in unison- with optimal hip-lumbopelvic control and good trunk and arm movements stacked on top of the lower body.


The hip flexors are a group of muscles that plays both the role of a stabiliser and the creator of hip movements. Deep hip flexor muscles stabilise the hip joint into the pelvic socket to bring your leg/thigh forwards through the swing phase when running. When it is tight or whenhip-flexors-in-action-v5-1024x576 we over activate this muscle group, each specific hip flexor muscle is unable to perform its role efficiently. So hip flexors that are stabilisers get weak from disuse, and global phasic hip flexor muscles get tight/fatigued and are prone to strains and injuries from overuse.


Many factors can cause hip flexor issues in runners. These include:

  1. Recreational runners, who mainly sit most of the day at work, are predisposed to tightness in their hip flexors due to postural issues from prolonged sitting.
  2. Tight hip flexors often then create altered alignment of the pelvis, commonly anteriorly tilting the pelvis, causing an exaggerated arch through the low back. When the pelvis is not in its neutral alignment, our hip extensors ie the gluteal muscles are then inhibited and becomes weaker, affecting one’s running efficiency, thus increasing the demands on one’s hip flexor muscles ( hence the feeling of chronically tight hip flexors)
  3. Weakness in the gluteal muscles, will create poor lateral stability of the hip-pelvic region. One commonly seen pattern, known as the Trendelenburg gait or ‘hip drop’. This in turn will create increase workload to the other lower limb muscles, including your hip flexors, quadriceps, hamstrings and calves, which can increase risk of muscle strains and other conditions like knee cap pain.


Hence, in tackling the hip flexor issues when running, we need to not only stretch the hip flexor muscles, but also any other lower limb muscles that may be fascially tight ( glutes, hamstrings, ITB, quadriceps, hip adductors), to enable us to achieve neutral alignment of our lumbopelvic-hip complex. Once we can achieve good postural alignment, we can then access the appropriate muscles when running.

The next stage to treatment, often involves core and gluteal muscles strengthening, to alleviate overloading our hip flexors when running. However, specific exercises to promote hip-pelvic dissociation and strengthening of our hip flexor muscles during swing phase of running needs to be focused on.

So with all the complex systems working to allow you to have an enjoyable and effective session, its no wonder how our daily activities can adversely affect our enjoyment of it.

So next time you run or exercise and the discomfort or tightness stops you cantering like a Group One filly at the Melbourne Cup remember….

Don’t fear, your PHYSIO is here!

Hip Pain – What’s the Cause?

Top 5 reasons

Hip pain is common in people who play sport. A lot of sports related hip pain is simply a sign of overuse- and will respond well to a few days rest. If it persists, it’s worth getting it assessed. Here are 5 common reasons for hip pain-:

Hip Pain - 2

Clue- its’ all about Location, location, location

Exactly where the pain is in the hip can be a strong clue as to the source of the pain. For example, pain that is deep, and more towards the groin is more likely to be related to the hip joint itself.clue-clipart-dT87enn6c

Pain on the outside of the hip is more likely to be tendon or bursa pain.

 Use the location of pain as a guide.

1. Adductor tendinopathy

The painbrian_kicking1web is usually towards the groin, and is worse with activities where you are on a single leg, or kicking. A very common injury in sports players where lots of kicking or running is involved.

Adductor injuries are common in kicking sports

2. Gluteus Medius tendinopathy / bursitis

hipPainDiagThis is the tendon of on of the gluteal muscles, and just like the tendons at the ankle (achilles) and the knee (patella) can become problematic. The pain tends to be on the outside of the hip (lateral hip pain), and can be painful to touch. The nearby bursa can also be inflamed and a source of pain.

3. Femoral-acetabular impingement (FAI)

faisThis is the funky, trendy diagnosis at present. The pain with FAI is usually deep and in towards the groin. The hypothesis is that people with a difference within the bony contours of the bone, in either the femoral head (the ball) or the the acetabulum (socket) will be more prone to pain from impingement. These are called either CAM or PINCER (see diagram). There is much controversy over how to diagnose this, and how to treat it. However, many patients can be successfully managed conservatively.

The funky and trendy diagnosis of the moment- FAI.

4. Referred pain from the lower back


Injuries in the lower back can refer pain to the hip. The pain is usually deep, or radiating across an area around the hip or upper leg. This is easily diagnosed by a physiotherapist, and treatment for the lumbar spine usually resolves this injury

The lower back can refer pain to the hip

5. Labral / cartilage tear 

This is an unusual injury but can be a cause of hip pain.The location of the pain is often deep, and towards the groin. If pain is associated with painful clicking at the hip then this diagnosis may be a possibility. Read more about Labral Tears here.

Hip Replacement – help!

My Father has just had his hip replaced…what on earth should he being doing?

Ok, so before we start getting into the nitty gritty of what exercises he should be performing, lets start by giving a brief overview of the operation, so you get some idea of the muscles that need to be strengthened.

There are various reasons why your dad may require a hip replacement but the most common is due to the hip joint wearing out (also known as osteoarthritis) which over time becomes painful……..…

But don’t worry, hip joint replacements are one of the most common and successful operations performed across Australia!

During the operation, your doctor cuts through the gluteal (bottom) muscles to gain access to the joint. Due to the muscles being cut and pulled around they’ll become weak, combined with the fact that your dad may not have used these muscles correctly before the operation, possibly causing further weakness!

But don’t worry, with the right exercises these muscles will heal and become stronger………

So, getting back to the original question…….…What exercises should he be performing after the operation?

These exercises should only be used as a guide and really require initial supervision from a physio. They target the gluteal (bottom) muscles, so due to the reasons given above, getting your dad to strengthen these muscles will improve his walking and general daily function.

So here we go….……

1. The classic bridge – On the bed, feet apart, arms out for support and squeeze the bottom muscles whilst raising up. Hold for 5 and slowly relax…… Repeat 3 sets of 10 reps.



2. The dreaded clam – This will burn! Lie on your side, legs bent, raise the operated leg up without rolling backwards. Hold for 5 and slowly relax………Repeat 3 sets of 6 reps.


3. The lateral raise – Stand on the good leg, arms out for support, keep the operated leg straight and raise it to the side without tilting your back to the opposite direction. Hold for 5 and slowly relax…… Repeat 3 sets of 10 reps.


4. Lastly – the single leg step down. This is a great way of improving strength of the entire leg. Stand on the operated leg, keep the hips level and perform a slight bend of the knee. Hold for 5 and slowly relax…… Repeat 3 sets of 6 reps.

So for the final point………

Advise your dad that when performing these exercises it is natural to feel a muscular ache around the gluts. Although after the exercise, the ache SHOULD subside.……Any acute sharp pain or pain the following day should be avoided so please consult your physio first!!

All dads are different and an exercise programme should be tailored to everyone of them!!

Piriformis Syndrome

What is piriformis syndrome?

Piriformis syndrome is a fancy way of saying that a tight buttock muscle (piriformis) is causing pressure on the nerve (sciatic) that passes underneath it. When this happens it can cause buttock pain and referral of pain down the leg (usually down the back of the leg). It may also cause pins and needles or numbness. Tightness of piriformis also restricts hip rotation.


Ending any diagnosis with the word “syndrome” often makes it sound like a terminal illness however, piriformis syndrome is generally not too serious and responds quickly to treatment so there’s no need to update your Will. Having said that, it can be a very painful condition if left untreated.

What causes it?

Piriformis syndrome is usually the result of one of three things:

  • Poor technique and hip control during leg exercises such as lunges, squats (especially single leg), running etc
  • Irritation of the low back joints
  • Irritation of the pelvic joints


How do I fix it?

For pain and symptomatic relief, the best treatment is to have the piriformis muscle loosened up. This can be done through massage, dry needling, or muscle energy techniques. Once the muscle is loosened, the sciatic nerve can pass more freely through the buttock musculature instead of getting tethered.

Contrary to what many people think is logical, stretching the hamstring does not help and often worsens symptoms. This is because the nerve is trapped under the piriformis muscle and stretching the hamstring creates a tug-of-war effect on the nerve as it ends up being pulled on by the buttock and hamstring in opposite directions.

Once the muscle has been loosened, the movement pattern causing the problem needs to be identified and corrected. Depending on the underlying cause, exercises often include correction of the pelvic posture and strengthening of the stabilising buttock muscles. Accuracy of performance of exercises is paramount to a quick recovery and avoiding recurrence. Your physio is the best person to guide you on technique and the most effective exercises you should perform.

SL bridge

Hip Pain – Labral Tear

The hip is a ball and socket joint.  A very big ball and quite a deep socket.anatomic-hip-620x380-zc-ns

But to help deepen the socket, and increase the joint stability,  there is a fibrocartilaginous ring around the outside of the socket. (coloured blue below)


If the ball is not centred in the socket optimally, abnormal wear patterns set up and, like any fibrocartilage in the body, degenerative wear patterns can appear.  These can progress into tears of the labral tissue which may cause significant catching type deep hip pain.

It was once thought that if a labrum is torn that surgical intervention (arthroscope and debridement (clear out) and/or repair) was the only solution.  However with rest and anti-inflammatory medication we can settle the acute inflammatory response and then try to evaluate whether there is a biomechanical causation.

Tight adductors (groin muscles), weak gluteals, overactive hip flexors can all have a significant effect in altering where the head of the femur (ball) sits in the acetabulum (socket).  Careful analysis of the deepest layer of muscles (the deep hip stabilisers – kind of like the rotator cuff of the hip!) using real time ultrasound may reveal timing deficits or poor control which can also have an effect on increasing labral stress.

Once the specific causation is worked out a plan of rehabilitation can be started and surgery may be able to be averted.   However if the labrum is being pinched by bony outgrowths (a condition called FemeroAcetabular Impingement – FAI – see image below)- it can be much harder to completely alter the biomechanical components.


One thing is for certain…a deep pinching pain in your hip or groin region needs investigating…so don’t put it off…get it checked out.