Hip pain is frustrating, trust me, I experienced it for about 2 weeks earlier this year and it sucked. Putting on pants was a struggle because I just couldn’t stand on that leg without either falling over or being in excruciating pain. I only experienced it for about 2 weeks so I’d hate to have lived with that for months or even years as some of my clients have.
Hip pain presentations can change a lot throughout the lifetime, from the gluteal tendinopathy that I experienced, to trochanteric bursitis, through hip osteoarthritis and management of clients post total hip replacement. Hips really do offer physiotherapists the full spectrum of what we need to manage.
Hip pain is a little bit more common in women than it is in men, mostly just due to the fact that women have slightly wider hips due to childbirth and pregnancy factors. This places extra stress on the gluteal tendon and bursal structures around the hip. Whereas men on the other hand are slightly more predisposed to groin pain.
Differential diagnosis of hip pain can be difficult, there are a lot of different structures that refer to the same areas. So much so that a convention was held to assist clinicians by determining clinical entities. They set aside 5 separate entities, hip-related pain, hip flexor-related pain, adductor-related pain, inguinal canal-related pain, and pubic symphysis-related pain. They then determined the best clinical tests and subjective findings for clinicians to help diagnose them. The hard part is, sometimes people fit 2, sometimes 3 of these entities, so how do we best manage this? We have a complex region, with a lot of factors that depend on each other. I’ll try to help you understand how I work with hip pain presentations and come to a clearer diagnosis that we can use to move forwards.
As with every other pain presentation, we start with how did the symptoms begin. As I mentioned above, for some people this could have been months or even years ago, but for me when I saw someone it was maybe two days after it started so I was able to really pinpoint how it started. If you can’t though that’s totally cool, usually, I may replace my question with what is the first thing you remember about the pain, this can be a really important question because it’s often the most significant moment that the client can recall rather than just the first moment.
Next, I want to try to understand how your symptoms have changed and developed over time and how the symptoms behave throughout the day. Changing symptoms over time such as an increase in tightness or stiffness to a certain area can help indicate what compensations might be happening as the body’s strategy to get away from the pain. Other people may feel that their other hip starts to get sore because it’s compensating (hint: that’s when it’s really time to get on top of something and not “wait and see what happens”). How the pain behaves throughout the day is also highly valuable information. Whether activities such as stairs, walking up an incline, squatting down, sitting for prolonged periods of time or sleeping aggravate your symptoms can give us really good insights into your pain and what may be causing it. It also gives us a good insight into how we can begin to structure an exercise program that both fits into your daily life and doesn’t aggravate your symptoms while allowing you to continue to live the life you want to and choose to. An exercise program shouldn’t become the be-all and end-all, you still need to be able to enjoy life.
Next up is determining whether you have any symptoms such as clicking, catching, or locking sensations. This could potentially indicate something happening within the hip joint so these are important symptoms to pass on if you are experiencing them.
The only other main factor left for us to discuss will be whether you have experienced any hip pain prior to this episode. A prior history of hip injuries or pain could potentially indicate there is more going on than what it may look like on the surface.
Assessing to differentially diagnose hip pain can be a tedious process. There are a lot of structures to try to rule out ranging from the lower back to the hip joint, to ruling out muscular or tendon presentation, and nerve pain presentations. There’s a lot going on in such a small area. As I mentioned above, a few years ago there was a consensus agreement on the definition and diagnostic criteria to assist clinicians in diagnosing hip and groin pain. The testing battery is short and concise with two to three tests for each entity. Once this has been narrowed down or ruled out the entities we can go a little bit more in-depth with our testing.
Specifically looking at the hip joint we are often looking at testing to stress the capsule around the hip joint or the surface of the socket of the joint. There’s a range of tests that we can perform to apply different types of stress. Positive tests are indicative that there could be something going on with the hip joint, they aren’t exactly the best tests at being specific, however, if you have positive tests coupled with painful clicking or clunking sensations my clinical suspicion of it increases.
For muscular tests, we are often wanting to perform isometric assessments of the muscles to isolate the contraction of the muscle and have as few other contributing factors in the test. Often I will perform an assessment of the hip flexor and adductors as standard but I may branch out with other tests should I feel the clinical need and depending upon the area of symptoms.
For a more specific diagnosis such as a greater trochanteric pain syndrome where the pain is quite localised to the side of the hip, there is again a specific testing process that I choose to run through. The testing combines tests that are both specific and sensitive. What that means is that if we are turning up consistent positive results, our clinical suspicion raises quite significantly.
One of my other favourite hip tests to perform is the Modified Thomas Test. This is a really nice test because it allows us to assess the length of a range of different structures ranging from the hip flexors, to the quads, to adductors, and the lateral hip complex including the glutes and tensor fascia latae.
Once we move beyond the clinical assessment procedure, we move on to the functional aspect of the assessment. This is really important, particularly for people who are having functional concerns with movements such as stairs, squatting, prolonged standing, or running. We will run through specific movement patterns to load and assess the capacity of the hip and pelvis to absorb load adequately. From this, we are able to begin to determine any areas of potential weakness or lack of motor control where we can develop an exercise program to address them.
Treating hip pain shouldn’t be too difficult if you come to a concise and accurate diagnosis. However, in some cases where the diagnosis may be a bit of a battle between two different choices, I will treat one pathway and treat it well and then assess the response. If I were to treat both, if you get worse I don’t know which treatment pathway made you worse. Conversely, if you get better, I also don’t know which one made you better. So I always err on the side of put all my eggs in one basket and then reassessing afterwards, treating two or more areas on an initial consult has almost always resulted in myself and my client getting confused.
Soft tissue release is probably my go-to treatment option around the hip joint. Releasing muscular tension can help to free up some movement around the hip and make movement throughout the day that little bit easier. The most common areas that I find I tend to be working on are the glutes, tensor fascia latae, and the hip flexor and quadriceps.
Another set of common techniques I will opt for is hip joint mobilisations, I find traction techniques of the hip joint can be incredibly effective for clients who are suffering from a hip joint-based presentation, whether it be osteoarthritis or a more acute injury such as a labral tear that a surgeon wants to trial non-surgical management on. Dry needling can also be highly effective around the hip joint in allowing us to get an isolated and specific effect on some of the deeper gluteal and hip rotator musculature.
As with everything else physiotherapists treat, a management plan isn’t complete without an individualised exercise program. For hips, these are so important and I really don’t think you can truly rehabilitate a hip injury without an exercise program, there will be too many movement adaptations and potential areas of weakness that I think your likelihood of another injury or insidious onset of pain will be too high. The majority of the work you should be doing should be strengthening work around the gluteals, hip flexors, core and abdominals. Developing the control and endurance of these muscles as well as power for specific movements and sports is vital for either returning to sport or just being able to maximise your quality of life.
Honestly, I don’t find there are many cases of hip pain that need a scan. Sometimes they can come in handy but more often than not we can come to a relatively clear diagnosis and treatment pathway. Most times I may refer to a GP for imaging in the cases that I suspect there may be an issue within the joint, or I believe referral to a surgeon may be recommended, or other avenues such as a cortisone injection could be of benefit.
Realistically the form of imaging that will be of benefit is entirely dependent on your symptoms and what we are trying to rule in or out. For issues within the joint such as a labral tear, an MRI would be your best option. If we are assessing a case of greater trochanteric pain syndrome ultrasound will be your best bet, an MRI doesn’t give significantly more information, and in most cases, we are looking at the bursa to assess whether a cortisone injection will be of benefit. An x-ray could be used in a few circumstances, bone stress injuries are a possibility though I may lean towards getting a CT scan for those, often I would refer for an x-ray in more of a paediatrics population to assess for any potential femoral head concerns.
Getting back on the sporting field is every athlete’s goal, I strive to send each athlete back on the sporting field a more complete and robust athlete than what they were when they got injured. Returning back to training and inevitably getting back to playing competitive games is a deliberate and planned process that needs to be mapped out from start to finish. Too often I hear of clients developing their own return to sport plan that often goes from “Yeah I’ll rest up” straight to “Yeah I’ll play a full game this week coach”. It’s better than I’ll just play through the pain but it can be a lot better than that.
Returning back to training needs to be a stepped progression. Often in the first session, I will get my clients to do some light running, and agility work, take part in the warm-up and complete some sport-specific movements or skill-based work. Assuming they respond positively to that we can begin to broaden our horizons from there. Often I will work to increase the speed and individual difficulty of drills an athlete is performing before I then return them to gameplay scenarios and eventually full gameplay.
To return to sport I have one major rule for athletes that I manage. They have to have completed at minimum one full training session prior to going back to play. Ideally, I would like to have had one full week of training but in some cases, this may not always be reasonable. For example, a client undergoing a two-week return to sport plan will have four progressions assuming they train twice per week. It’s not often that I will be able to progress to full training by the third session so the fourth will become the only full training session we have planned. Whereas an athlete undergoing a three-week plan, in most cases we will be able to manage it so that the third week is a full training week.
Our 3-week program was designed for clients who have suffered an acute injury and want to get out of pain ASAP. This package could be suitable for clients who have suffered the recent onset of hip pain at the front or side of the hip, suffered a low-grade muscle strain, or
Our 3-week program is inclusive of the following:
Package price: $770
Our 6-week program is designed for clients who have sustained a higher-grade injury. This could include clients who have a longer period of hip symptoms (often around 1 month or longer), a moderate to higher grade muscle strain, early cases of greater trochanteric pain syndrome, or osteoarthritic symptoms.
Our 6-week program is inclusive of the following:
Package price: $1050
Our 12-week program is designed for clients who have sustained higher-grade or longer-term symptoms such as greater trochanteric pain syndrome or gluteal tendinopathy, longer-term hip pain, or osteoarthritis presentations.
Our 12-week program is inclusive of the following: