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Evidence-based providers can tell you the exact tissue origin of pain via history, physical examination, and possible diagnostic imaging.  Without an understanding of specific tissue injury, deciding on appropriate treatment is futile.  While many hip pathologies result in pain, it would be impractical to treat all hip pains with the same protocol.  Today’s blog will cover one essential component of EB chiropractic practice—focused treatment.

The following information is from ChiroUp guest expert Dr. Micheal Braccio of the ACA Rehab Council.

Watch the full 50-minute interview.

Conversation Points

6:08 – Signs of hamstring issues

7:07 – Differentiating sciatica from proximal hamstring strains

24:32 – pincer and cam impingement vs. adductor strain

34:22 – Dr. Steele’s top two hip diagnoses

42:10 – Load heavy and often

Proximal hamstring injuries, gluteal tendinopathies, adductor strains, femoral-acetabular impingement, and osteoarthritis are common presentations in chiropractic clinics. Consider using these recommendations with your next hip pain patient to improve your clinical success and patient satisfaction.

Proximal Hamstring Strain

Ischial tuberosity pain often associated with a younger, athletic population

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 take 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 that incorporate trunk stabilization and progressive agility drills decrease re-injury rates when compared to more traditional isolated stretching and strengthening programs. There is significant evidence suggesting that the incorporation of (Nordic) eccentric strength training exercises assists in the rehabilitation of hamstring injuries and minimizes recurrence.

Gluteal Tendinosis

Local achy pain along the posterior greater tuberosity

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, band walk, 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

 

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, high repetition. Early rehab should include strengthening the trunk, upper body, and contralateral lower extremity, as well as pain-free balance board exercises.

TIP #2

Return to sport-specific activity can generally begin when an athlete regains full pain-free range of motion and at least 75% full strength. The ultimate goal of rehab would be to restore adduction strength equal to the uninvolved side and adduction strength that is at least 90-100% of abduction strength. The majority of 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 as long as six months.  Discomfort following return to play is not uncommon.

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

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 consists of 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.  Surgical intervention, when performed before the significant degenerative changes have ensued, provides favorable results. 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.

TIP #1

Management of hip OA should focus on restoring motion and avoidance of aggravating factors. In recent years, several well-constructed RCT’s and other studies have demonstrated that manipulation of the hip is a particularly effective treatment for hip OA.

TIP #2

A systematic review concluded that manual therapy and exercise therapy are beneficial for 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 greatest and most 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 appropriate.

REMEMBER

  1. A positive FABER test is positive for hip dysfunction, diagnosis is still dependent on the LOCATION of pain provocation. Reproduction of lateral hip pain may be indicative of gluteal tendinopathy.  Exacerbation of groin pain suggests intraarticular pathology, i.e., OA.
  2. The inability to put on and take off shoes and socks points to an acetabular condition like FAI and OA of the hip. (1)

After countless conversations, many meetings with large chiropractic clinic systems, and learning from hundreds of ChiroUp members, there is one differentiator that successful chiropractors possess—those who “classify” and those who don’t. There are outliers in any patient population, but the majority of patients fall into a diagnosis “bucket.” 

ChiroUp allows you to manage patients with better organization, improved patient compliance and greater clinical effectiveness.

If you’ve had some extra time on your hands, I invite you to create a ChiroUp account. During this trying time, we are offering an extended trial so that our platform can be accessible to all DCs.

Whether you’re looking for an online resource to streamline your telehealth calls, or maybe you want to kick-start some marketing projects, ChiroUp is here to help.

If you have any questions, please feel free to reach out directly to me: Brandon@ChiroUP.com.

Together we can emerge stronger.

References
  1. Fearon AM, Scarvell JM, Neeman T, Cook JL, Cormick W, Smith PN. Greater trochanteric pain syndrome: defining the clinical syndrome. Br J Sports Med. 2013 Jul 1;47(10):649-53. Link
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    About the Author

    Dr. Brandon Steele

    Dr. Brandon Steele

    DC, DACO

    Dr. Steele is currently in private practice at Premier Rehab in the greater St. Louis area. He began his career with a post-graduate residency at The Central Institute for Human Performance. During this unique opportunity, he was able to create and implement rehabilitation programs for members of the St. Louis Cardinals, Rams, and Blues. Dr. Steele currently lectures extensively on evidence-based treatment of musculoskeletal disorders for the University of Bridgeport’s diplomate in orthopedics program. He serves on the executive board of the Illinois Chiropractic Society. He is a Diplomate and Fellow of the Academy of Chiropractic Orthopedists (FACO). His mission in practice is to get people in and out of pain as fast as possible; then give each patient the education and rehabilitation to never see them again. Dr. Steele is also the co-founder of ChiroUp.com, a resource used around the world by practicing chiropractors and colleges.

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