The hip joint is formed between the inwards facing ‘ball’ at the top of the thigh bone and the deep ‘socket’ (acetabulum) on the pelvis.
Arthritis of the hip
Arthritis at the hip is most commonly osteoarthritis, usually presenting in the over 60s. There may be no obvious cause or it may be due to overuse, previous broken bone (fracture) in the region or altered posture (biomechanics) leading to uneven stresses through the joint. It affects men and women and passes through stages with increasing pain on standing and walking, stiffness and difficulty in getting comfortable at night, disturbing sleep. The pain is usually felt in the groin and front of the thigh but it may travel to the front of the ankle and can be felt in the low back and buttock. For this latter reason, thorough assessment is needed to separate it from back pain as the main. Stiffness and pain of movements in a particular pattern will help with diagnosis.
Physiotherapy can help, especially in the early stages by using stretching techniques to improve the range of movement and to relieve pain. Home exercises are given to prevent the hip joint stiffening after treatment with advice on posture and general activities.
Top up treatments might be needed and if the treatment stops helping then referral for an orthopaedic opinion is appropriate to see if injection or surgery is indicated.
Loose body in the hip
Loose bodies are small fragments of cartilage or bone that can form in joints; particularly the hip, knee and elbow.
Loose bodies don’t have to cause problems and they can often be stable and fixed within the joint space. If they are free in the joint they may become trapped between the bony joint surfaces where they may give rise to twinges of pain, locking of the joint or blocked or ‘springy’ movements.
A loose body in the hip joint causes twinges of pain felt in the groin or radiating down the front of the leg. There may also be the sensation of the hip locking or giving way and the patient may feel unable to put weight through the leg. The condition is most commonly associated with osteoarthritis in the hip.
Physiotherapy can help by applying a special technique that stretches out the joint a little to give the loose body room to move, and then applying a few sharp flicks to jolt the loose body into a more comfortable position. If the pain is severe and debilitating surgical removal may be necessary and if associated with advanced arthritis, joint replacement or resurfacing may take place at the same time.
Bursitis at the hip
A bursa is a thin flattened fluid-containing balloon that acts as a buffer where muscles pass over bony points or it may lie between two muscles pulling in different directions to reduce friction. It can also protect bony prominences where they lie just under the skin.
Bursitis is inflammation of a bursa and it is associated with swelling and pain. Three main bursae may be involved in bursitis at the hip: the psoas bursa, trochanteric bursa or, less commonly, the ischial bursa.
The psoas (‘so-ass’) bursa lies in front of the hip joint and sits underneath the powerful muscle that bends the hip and the trunk. Psoas bursitis produces a local groin pain that can travel downwards to the knee or shin. The pain usually comes on gradually and the patient finds it hard to recall what might have brought it on although it is likely to be caused by overuse and sudden unaccustomed activity, such as bike riding, fell running or a weekend of decorating involving climbing ladders. The patient will complain of pain on bending to put on socks, walking upstairs or leaving the leg behind whilst walking. Any bursitis presents with a ‘muddle’ of signs with several movements being painful. Careful assessment is needed to distinguish the problem from other hip joint conditions or the pain could also be referring from the back, including the sacroiliac joint.
Physiotherapy can help by explaining the condition and advising on avoiding aggravating activities to allow the pain to settle. Electrotherapy can be used for pain relief and to promote healing. If the response to treatment is slow, an injection of anti-inflammatory steroid may be given to speed recovery.
There are several trochanteric bursae that sit between the gluteal muscles in the buttock and the large bony prominence on the side of the hip. The most superficial of these bursa is the one more often involved in trochanteric bursitis. Trochanteric bursitis can come on after a direct blow to the side of the hip, as in falling onto a hard floor but it more commonly comes on with overuse through occupational or sporting activities. There may be posture or biomechanical problems that have caused the problem over time and it may be associated with osteoarthritis of the hip as well.
The patient will complain of tenderness at the side of the hip and an aching or burning pain down the outside of the thigh. Walking, standing for prolonged periods, crossing the legs or lying on that side may aggravate the pain. There is normally a ‘muddle’ of signs with several different movements bringing on the pain.
Physiotherapy can help by applying soft tissue massage and stretches to the area and electrotherapy can be used to reduce pain and to promote healing. Advice will be given on posture and resting from aggravating activities. An injection of anti-inflammatory steroid may be more effective if response to treatment is slow.
The ischial bursa sits between the gluteus maximus muscle and the bony prominence in the buttock (the ischial tuberosity). The bone can be felt more easily when in the sitting position. Ischial bursitis is also known as ‘weaver’s bottom’ and it can come on after prolonged sitting on hard surfaces, with the pain being relieved by standing. It is a rare cause of buttock pain but when present the principles of treatment can be applied as for trochanteric bursitis.
There are three hamstring muscles that arise at the bony prominence in the buttock (the ischial tuberosity) and their tendons attach below the knee. They pull the hip backwards and bend the knee. Injury can occur within the belly of the muscles, the tendons or where the muscle meets the tendon (the musculotendinous junction).
Injury usually happens suddenly with overstretching of the hamstrings that can happen with burst of activity, such as in starting to sprint, and it will produce acute pain making it difficult or even impossible to continue with the causative activity. If severe, particularly if the muscle is injured, bruising and swelling will develop and the patient may need crutches to be able to walk. The back of the thigh will feel stiff and there may be painful muscle spasms. As the acute condition subsides the patient will complain of pain on bending the knee against resistance and lifting the leg with the knee straight will stretch the injured area producing pain.
For both the tendon and muscle belly injury, Physiotherapy can help by advising on care of the area in the acute stage when ice and gentle movement are appropriate. After 48 hours or so, gentle massage and a specific technique called frictions can be applied across the tender area followed by relative rest for the tendon and early movement in the pain free range for the muscle belly. As the acute stage subsides, the frictions and massage may be applied a little more vigorously and the range of movement can increase, provided it remains pain free.
Stretching as such will not be advisable until the patient can jog without pain and bending the knee against resistance does not cause pain. Patients tend to start stretching much too early and the importance of giving the muscle or tendon time to heal will be explained. Electrotherapy may be used; this is often ultrasound to relieve pain and to promote healing but interferential may also be used to encourage the muscle to contract and broaden but without disturbing the healing muscle fibres. Clear advice will be given for the progression back to full activity.
Quadriceps muscle injury
There are four quadriceps muscles that arise from the pelvis and thigh bone and all attach to below the knee through a large tendon (patellar tendon). The knee cap (patella) sits within the tendon as it crosses the font of the knee. Conditions affecting the tendon will be covered under ‘knee conditions’. Together the muscles straighten the knee but their main action is to control the bending of the knee whilst going downstairs or walking. One of the quadriceps muscles attaches above the hip and will also help to bend the hip (rectus femoris).
Injuries to the quadriceps muscle can happen in a similar way to the hamstring muscles where a sudden stop while the muscle is contracting can lead to tearing of muscle fibres, as in kicking the ground instead of the football. The patient will present with pain in the front of the thigh with pain on straightening the knee against resistance and on stretching the area while bending the knee.
It is usually the most superficial muscle of the group that is injured and bruising and swelling are usually apparent in the muscle belly. The muscle is treated with ice, massage, frictions and interferential therapy, as given for hamstring muscle belly injury, with advice on the progression back to full activity and the warning not to stretch too soon.
Groin strain (adductor longus injury or ‘rider’s strain’)
The adductor longus muscle arises in the groin from the pelvis and runs down the inside of the thigh to attach to the middle of the thigh bone. It is one of three adductor muscles and their main action is to bring the leg back towards the midline.
Injury usually happens through overuse such as in working a horse while riding – thus ‘rider’s strain’. It may be injured at its attachment to the pelvis or where the tendon meets the muscle (musculotendinous junction). Pain will be provoked by pulling the leg towards the midline against resistance and by stretching the area by taking the leg to the end of range away form the mid line.
Physiotherapy can help with treatment including soft tissue massage and a specific massage technique called frictions across the tender area. Ice and electrotherapy may be used, particularly ultrasound, to relieve pain and the promote healing. Care must be taken not to stretch too soon as healing could be delayed. Advice will be given for the return to full activity.
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