What Causes Hip Pain?
Reading time: 6 minutes
Some of the greatest hypocrites I have ever known are chiropractors. I have fallen into this category on many occasions! We all claim to treat the entire body; however, anything near the back, hip, knee, leg, or foot is a back problem until proven otherwise. Today's blog dives into six typical causes of hip pain. Then, provide the top tests to identify the proper diagnosis and tips to help treat these very different dysfunctions.
Hip Labral Tear
Groin achiness upon sitting. Sharp pains, clicking, or a catching sensation with end-range hip motion.
Identify with the Anterior Hip-Impingement Test (AKA FADIR): The most consistent physical exam finding in patients with acetabular labral tears is a positive anterior hip-impingement test. This test is performed with the patient supine with the hip and knee at 90° of flexion. The hip is internally rotated while an adduction force is applied—positive test results in pain provocation to the anterolateral hip or groin.
Tip #1 When dealing with hip pain from a labral tear, it is essential to be mindful of sitting positions. Have your patients avoid sitting with their knees lower than their hips or crossed legs. Instead, try having your patients sit on the edge of their seats to avoid placing pressure on your femur, as this can cause pain in the hip joint. Instead, the pressure should be on the ischial tuberosity. Placing pressure on the ischial tuberosities will decrease pressure on the hip joint.
Tip #2 Excessive hip internal rotation and extension provoke hip pain in patients with a labral lesion. These motions are associated with fast walking or running. Also, remember to assess foot motion that may affect hip motion. Stiffness within the subtalar joint, ankle mortise, and midfoot may lead to excessive motion needed through the hip. Improved mobility through these joints can reduce the hip range of motion and improve gait patterns. (1)
Proximal Hamstring Strain
Ischial tuberosity pain that is often associated with a younger, athletic population.
Identify with the Hamstring Drag Test: This test is performed by asking a standing patient to take off the shoe of the injured leg while holding that shoe on the ground with the forefoot of the unaffected leg. a.k.a. Take off the shoe test" (TOST).
TIP #1 The proximity of hamstring injury to the ischial tuberosity generally correlates with the recovery period. Proximal injuries (at the ischial tuberosity) often require more extended convalescent periods. Tissue damage resulting from slow-speed stretching typically takes longer to heal. Recurrent injuries often take twice as long to heal as the initial injury. Athletes who do not adequately rehabilitate their injury and return to a sport prematurely are at higher risk of re-injury and diminished performance.
TIP #2 Rehabilitation programs incorporating trunk stabilization and progressive agility drills decrease re-injury rates compared to more traditional isolated stretching and strengthening programs. There is significant evidence suggesting that incorporating (Nordic) eccentric strength training exercises assists in rehabilitating hamstring injuries and minimizes recurrence.
Eccentric Hamstring Exercise
Gluteal Tendinosis
Local achy pain along the posterior greater tuberosity
Identify with The Hip Lag Sign: performed with the patient in a side-lying position, affected side up. The clinician stabilizes the patient's pelvis with their knee while supporting their knee and ankle. Then, the clinician will passively move the patient's hip and thigh into 20 degrees of abduction, 10 degrees of extension, and maximal internal rotation. The patient's leg should remain relaxed with the knee bent at 45 degrees. After asking the patent to hold their leg in this position actively, the clinician releases support. The test is positive if the patient cannot maintain this position and the foot drops more than 10 cm. The Hip Lag Sign demonstrates high sensitivity (89.5%) and specificity (96.6%) for hip abductor tendon injury. (2)
TIP #1 Eliminating modifiable risk factors and faulty mechanics that cause excessive tensile or compressive loading. Avoid sleeping on the affected hip. Consider using this ADL for your patients with gluteal tendinosis.
TIP #2 Implement early and progressive restorative loading to improve tendon integrity and load-bearing capacity. Gluteus strengthening might include a combination of single-leg stance, single-leg squat, glute squeezes, bridging, side planks, lunges, side steps, step-ups, skater squats, and side plank with abduction exercises.
Adductor Strain
Localized groin pain associated with multiplanar sports like soccer and racquetball
Identify using the Thigh Adductor Squeeze Test: a provocative orthopedic maneuver where the supine patient forcefully adducts their thighs to compress a fist or ball between their knees. This maneuver is performed first with the knees fully extended to stress the adductor magnus and gracilis, then in a supine hook-lying position with 45-60 degrees of hip flexion to stress the adductor longus and the pubic joint, and finally at 90 degrees to stress the pectineus and abdominal muscles. Incorporating a sphygmomanometer or dynamometer for measurement affords a quantitative assessment of baseline disability and subsequent improvement.
TIP #1: Strengthening begins with pain-free isometric adduction and non-weight bearing progressive resistance for hip flexion, extension, and abduction – i.e., low load and high repetition. Early rehab should include strengthening the trunk, upper body, and contralateral lower extremities and pain-free balance board exercises.
TIP #2: Return to a sport-specific activity generally begins when an athlete regains a full pain-free range of motion and at least 75% full strength. The ultimate goal of rehab would be restoring adduction strength equal to the uninvolved side and adduction strength of at least 90-100% of abduction strength. Most groin strains permit the return to play in less than four weeks. Moderate acute strains typically recover in four to eight weeks, while chronic strains may persist for as long as six months. Discomfort following a return to play is not uncommon.
Copenhagen Adductor Strengthening
Active treatment of bone-tendon injuries may necessitate delay until acute symptoms improve. Tears involving the more vascularized musculotendinous junction or muscle belly can generally tolerate an earlier rehab.
Femoroacetabular Impingement (FAI)
Deep and often sharp groin pain exacerbated by hip flexion activities
Identify using the FABER test: FABER test is the most common test to assess for hip joint pathology. There are two different types of FAI (cam and pincer). Check this past blog to learn how to correlate these test findings with patient symptoms.
TIP #1 While there is no evidence to support or refute the non-surgical management of FAI, the condition merits consideration of conservative care before surgery. Conservative management includes patient education, activity restriction, proprioceptive training, manual therapy, and stability/strengthening.
TIP #2 Manipulation of the lumbar spine and sacroiliac joints may be appropriate. Passive hip mobilization and distraction may help improve hip mobility, particularly in the presence of osteoarthritis. Still, clinicians should avoid aggressive hip mobilization or manipulation, as these movements may exacerbate the problem. Likewise, clinicians should avoid stretching or passive range of motion exercise, which is counterproductive.
Patients who fail a trial of conservative care may require surgical intervention to limit progressive degeneration. Delaying surgical intervention for up to twelve months has little effect on the outcome. However, longer delays lead to worse outcomes. A surgical intervention provides favorable results before significant degenerative changes ensue. Clinicians should not delay surgical consultation for unresponsive or refractory cases. Surgical management of cam-type disorders includes resection of the femur head-neck junction, while pincer-type correction includes resection of the acetabular rim with preservation of the labrum.
Hip Osteoarthritis
Vague deep groin pain with hip internal rotation and flexion.
Identify using the Hip Scour Test: The patient is supine with the examiner standing on the involved side. The clinician passively flexes the patient's hip to 90 degrees with the knee in full flexion. The clinician then adducts the hip and applies a downward force along the shaft of the femur while passively internally and externally rotating the hip. The clinician then passively abducts the hip and applies a downward force along the shaft of the femur while passively internally and externally rotating the hip. Any pain, apprehension, or unusual movement indicates a positive (non-descript) sign of acetabular or labral pathology.
TIP #1 Management of hip OA should focus on restoring motion and avoiding aggravating factors. In recent years, several well-constructed RCTs and other studies have demonstrated that hip manipulation is a particularly effective treatment for hip OA.
TIP #2 A systematic review concluded that manual therapy and exercise therapy benefit people with hip osteoarthritis in terms of reduced pain, improved physical function, and improved quality of life. Several studies favor manipulation versus exercise, and some show that manipulation created the most significant and beneficial gains in range of motion and pain reduction of all therapies studied. Manipulation of contiguous regions, including lumbar, sacroiliac, and lower extremity joints, is also appropriate.
There is one differentiator that successful chiropractors possess—those who "classify" and those who don't. There are outliers in any patient population, but most patients fall into a specific diagnosis. Identifying the proper diagnosis and delivering the corresponding treatment advice regarding the hip improve patient compliance and satisfaction.
If you want to incorporate this knowledge into your practice immediately, I invite you to start a trial with ChiroUp.
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Leardini A, O'Connor JJ, Giannini S. Biomechanics of the natural, arthritic, and replaced human ankle joint. J Foot Ankle Res. 2014 February 6;7(1):8. doi: 10.1186/1757-1146-7-8.
Kaltenborn A et al. The Hip Lag Sign - Prospective Blinded Trial of a New Clinical Sign to Predict Hip Abductor Damage. PLOS One March 12, 2014.
