As you can see from this previous blog sydneyphysiosolutions.com.au/hip-pain-whats-cause, there are numerous different causes for Hip pain, which will then display itself with different signs and symptoms.
As a general rule, Hip Pain can be avoided by working on two major areas, as well as stretching regularly:
- Lumbo-Pelvic Stability (your core) -> Pilates!
- Gluteal strength
Whatever sport you play, even just walking around in everyday life requires a percentage of ‘single leg stance’ phase in weight-bearing. These demands obviously become greater if expected to land, hop, balance, run, twist and turn, demanding more from our single-leg stance and stability. To be able to stand on one leg requires our ‘core’ (Transversus Abdominus) to engage, to assist our “force-closure” of the pelvis which means that the bones of our Pelvis and Spine are kept together and in the best possible position for them in order for us to be able to transfer weight between each leg. This is best learned and practised with Pilates-style training.
Additionally to single-leg stand, we require the Gluteals – both Glute Maximus and Medius (as well as the other smaller glute and groin muscles) to activate. The biggest gluteal muscle is our glute maximus – this is the no.1 muscle that I would suggest working on to avoid Hip pain, as it is a powerful Hip extensor, aids the stability of the pelvis, and is required to function in addition to gluteus Medius in stabilising the lower limb. This is easily exercised using a squat.
Key to the squat is to keep your back straight and ‘hinge’ from the Hips, sticking your bottom out behind you, with your weight in your heels. I would perform 3×10 for starters.
The Hip Joint
The hip joint is a multiaxial ball and socket joint, rather like the shoulder joint. 
It joins the pelvis (acetabulum) to the lower limb (femur). The main difference is that the socket in the pelvis is much deeper than the shoulder and almost completely covers the articular surface of the ball of the hip bone.
To further deepen the socket there is a fibrocartilaginous labrum around the edge of the acetabulum.
The deepest layer of muscles is responsible for stabilizing the ball within the socket and the more superficial muscles are responsible for movement generation and power. Tendons attach these muscles to the bone at both ends.
When to See a Health Professional
Ask someone to drive you to urgent care or the emergency room if your hip pain was caused by an injury and is accompanied by:
a joint that appears deformed,
inability to move your leg or hip,
inability to bear weight on the affected leg,
intense pain, sudden swelling and any signs of infection (fever, chills, redness).
If the hip pain is minor you may be able to manage it with rest, ice and anti-inflammatories.
Overuse of Muscles & Tendinitis in the Hip
Gluteal tendinopathy is one of the most common tendon injuries in the hip.
It is most frequently located in the gluteus medius or minimus tendons and is often associated with bursitis. Although overuse is a common cause of tendon injury, in the lateral hip compression of the tendons at the insertion on to the bone is thought to be an important factor.
Compression on the tendons can be caused by increased tightness in the ITB, as well as increased tightness and overactivity of other superficial lateral hip muscles (e.g TFL, vastus lateralis), as they attach over the gluteus medius and minimus tendons.
Additionally, postural compression can occur from functional adduction of the hip. For example, sitting with one leg crossed over the other, lying on your side with the top leg in adduction, or standing ‘hanging off’ one hip. As well as compression, weakness through the gluteus minimus and medius muscles can result in the development of tendinopathy in the hip. Therefore, treatment needs to be targeted to a multitude of factors to ensure a positive outcome and prevent further injury.
Cartilage Damage & Fracture
Cartilage damage to the hip can occur through general wear and tear, increased heavy loading, (e.g from a heavy fall or high impact sports), or sometimes from inactivity and prolonged periods of immobility. In this instance, the cartilage is not being nourished enough by movement and can wear thin. Fracture of the hip is often due to high-level trauma such as a car accident, a fall onto the joint, or a deterioration in the joint condition. This may present with pain on weight bearing, inflammation around the joint and a loss of range of motion and function. A fractured hip is very painful, and if suspected should definitely be managed medically.
Labral Tear & Hernia
The hip is a ball and socket joint that has a ring of fibrocartilaginous tissue around the socket perimeter which increased the depth of the socket and increases joint stability (see pic). Labral tears can develop over time from poor, repetitive movement patterns often causing a catching type pain. Treatment consists of an assessment of the superficial and deep surrounding muscular to determine what is overly tight, underactive or overactive. Real-time ultrasound is a great way to assess this and direct treatment to the source.
A hernia refers to when a part of the bowel protrudes through the abdominal wall. When this occurs in the hip it is called an inguinal hernia and happens in the groin region. Symptoms may include sharp pain with abdominal exercises, coughing or when taking a large step. Treatment may be either conservative, consisting of retraining of the deep abdominal muscles, or if severe, may require surgery.
If you think you may be suffering from either of these ailments it’s best to see your physio ASAP!
Symptoms of Hip Problems
Depending on what is causing their hip pain, people may feel pain in their thigh, inside the hip joint, outside the hip joint, groin, buttocks, lower back and inner knee.
People may notice that their pain is worse with activity or rest. Symptoms of hip pain can be reduced movement, muscle stiffness, limping, and pain.
Nerve Problems
In many cases, pain around the hip and pelvis can be originating from a nerve. Nerve symptoms often involve;
- A burning type pain
- Sensory changes like pins and needles, tingling or numbness
- Muscle weakness
- Reflex changes
Nerve problems around the hip can often be caused by compression and become entrapped due to poor muscular function. The most common nerves that are compressed or entrapped around the hip are;
- Sciatic nerve – from the overactive piriformis muscle. Usually as a result of weakness of the lumbo-pelvic stabilizing muscles. Pain may extend from the buttock all the way down to the calf.
- Obturator nerve – common in cyclists in which their nerve is compressed directly as a result of sitting for prolonged periods of time.
- Lateral femoral cutaneous nerve – the nerve can sometimes be compressed or damaged as a result of a seatbelt during an accident.
Nerve problems around the hip can also be as a result of an inability to stretch or glide smoothly when we move. This is called neural tension. The sciatic and femoral nerves are often involved and can be easily reversed through physiotherapy gliding and tensioning exercises.
Treatment of the Hip
Treatment:
Hip pain can result from a variety of different sources and can result in a variety of different treatments.
Decreasing initial pain and inflammation is important with ice, anti-inflammatory medication, taping, massage or mobility aids.
Restoring range of motion and function with guided mobilisations, strength exercises and individual home exercise programs from your physiotherapist.
Preventing exacerbation by controlling your body weight, strengthening your bones and keeping generally active with pain-free exercise!
Hints for self-management
- Activity modification is initially important to reduce irritation to the hip joint
- Anti-inflammatory medications may help to reduce swelling and pressure in the hip joint allowing more space for the ball to move in the socket and ultimately alleviating the pain experienced.
- Slow onset of pain is more likely to indicate an overuse injury which causes inflammation or a degenerative-type of injury such as osteoarthritis
- An acute injury will more likely indicate a tear/strain of muscles, ligaments or the labrum
Management options
- Conservative management aims to strengthen the muscles that support the hip and loosen off tight structures, this decreases aggravating loading patterns
- Surgery to correct labral tears and improve joint mechanics
- Medication or injections to reduce inflammation
- Rest to allow structures to heal
Osteo & Other Types of Arthritis in the Hip
There are 2 main types of Arthritis – Osteo and Rheumatoid.
Osteo is the loss of cartilage from one or both of the 2 surfaces that make a joint. Cartilage in the hip is between 1-4 mm thick. It is an excellent shock absorber and protects the bone it is attached to. If it wears down through injury or use the bone is irritated, it inflames and is painful.
Broadly speaking Rheumatoid occurs when the body attacks itself. The body’s immune system thinks something good in the hip joint is bad and sends in a mixture of chemicals and combative cells to deal with the situation. Inflammation results which results in pain.
Osteoarthritis of the hip generally responds poorly to surgical intervention, but does respond rather well to specific muscle retraining. If a hip’s cartilage wears down enough to create a debilitating amount of pain then a hip replacement is considered. This operation has a long background of excellent outcomes.
Rheumatoid arthritis is rarely confined to one joint. It normally will affect multiple joints and move around the body without a pattern. It is normally managed as well as possible with medication which a Rheumatologist will prescribe.
Osteoporosis & Synovitis
Osteoporosis is a condition characterised by reduced bone density, due to a loss of bone minerals, which can lead to an increased risk of fractures and bony injury. A person with osteoporosis may have no symptoms, until an injury occurs. If you have risk factors, which may include being over the age of 50, having a family history of osteoporosis, a history of low intake of calcium, and/or vitamin D, certain medical conditions, or adverse lifestyle factors such as smoking, or low physical activity levels, it is worthwhile seeing your doctor.
Osteoporosis in the hip can weaken the structure of the hip joint putting a person at greater risk of injury from trauma and stress to that joint. Hip fractures are one of the most common fractures associated with osteoporosis and the consequences can be severe.
Reducing modifiable risk factors such as diet, quitting smoking and participating in appropriate exercises to help prevent deterioration of bone density and increase your lower limb strength and balance to reduce falls in a great start. Best advice is to ask your doctor or physiotherapist.
Synovitis of the hip:
Synovitis, or irritable hip, is the inflammation of the inner lining of the hip joint, the synovium. This condition is characterised by acute hip pain, reduced comfort in weight bearing, and stiffness and is often associated with other injuries in the hip such as labral tears, impingement or arthritis. As pain is likely to be present, prior to the diagnosis of synovitis, a thorough assessment of the cause of hip synovitis should be made, which will include determination of any contributing hip pathology. Appropriate treatment such as physiotherapy, rehabilitation exercises or rest can then be undertaken.
A specific type of this condition called Transient Synovitis, which presents as a sudden onset of hip pain, possibly caused by an infection or virus, usually affects children and typically without an associated injury. Any presentation of this type should always be investigated thoroughly.
Treatment will be determined by the cause of the synovitis, but may include rest, anti-inflammatories, and appropriate activity modification and exercises. See your GP or physio if you are experiencing hip pain.
Interesting facts & more information
- Labral tears have become a more common finding in the last 10 years due to improved tests and treatment procedures
- Repetition in sports such as soccer, gymnastics and ballet result in a high percentage of athletes with a labral injury
- The hip is a ball and socket joint, surrounded by thick bands of tissue, which create a very stable and deep joint.
- The hip is made up of two bones: the femoral head or thighbone and the acetabulum or hip socket.
- Other causes of hip pain can include bursa Inflammation (fluid filled sacks which provide lubrication between bones and ligaments)
- Osteoarthritis is the most common cause of hip pain in people over the age of 50
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