The hip joint is unique in that it’s almost always being put to use and bears weight with every step you take. Since it’s constantly moving, the hip joint is the second most commonly affected large joint in the body. The size and the mechanical complexity of the hip joint also makes it prone to injury. Although a ball-and-socket joint provides a wide range-of-motion, there is a trade off between mobility and stability. Due to the lack of stability, ligaments and muscles that surround the joint work to provide stability. However, if there are imbalances with these muscles, they can lead to pain in the area.
Understanding Causes Of Hip Pain
With hip pain, it’s important to determine whether the pain is the result of a long-term condition of the joint or an acute injury. Pain could be due to lifestyle, physical injuries, mechanical problems, or a type of musculoskeletal condition. Even the type of shoes you wear can lead to hip pain. Your age, previous injuries, and types of physical activities you engage in all affect your risk for hip pain. In the United States, 7% of all adults report having hip pain. With adults aged 65 or older, about double the amount (15%) report having hip pain throughout the day.
Chronic Hip Pain
Long-term hip pain usually develops due to overuse with repetitive and demanding movements or any past trauma to the joint. If you have tight hip flexors or weak glutes, they are common precursors to chronic hip pain.
There are typically 2 reasons why your muscles may be tight. They may be compensating for weakness elsewhere or they are held in a shortened position for a long period of time. If your job requires you to sit for most of the day, your hip flexors, located in the front of your leg, are in a constant shortened position. Additionally, your glutes are not activated while your are sitting and may not know how to “turn on” when needed.
Your gait can also affect your hip flexors. Many of us over rely on our knees and quads to walk or run and we don’t engage our glutes. For runners who are more quad and hamstring dominant, rather than glute dominant, your body compensates for this imbalance with tightening your hip flexors. Weak glutes causes your hip and pelvis to be off, leading to wear and tear of the hip joint.
Other chronic hip pain conditions include:
• Sciatica and piriformis syndrome: Hip pain related to sciatica is caused by 2 forms of inflammation: 1. inflammation resulting in the compression on the sciatic nerve on the lower spine and 2. inflammation of the piriformis muscle near the back of your hip resulting in the compression of the sciatic nerve in that region. If sciatica is caused by an inflammation in the L4 and L5 vertebrae, you may feel radiating pain down the back of the leg to the knee. If it’s caused by piriformis inflammation, you may feel a more localized pain in the hip and gluteal region.
• Snapping hip: Similar to pulling back on a rubber band, the same tension relationship happens with your muscle and a snap can occur when the muscle rubs on a bone. External snapping hip occurs when your IT band snaps over the greater trochanter, near the top of your femur. Internal snapping hip occurs when your tight hip flexor rubs on the bony part of your hip.
• Trochanteric bursitis: Unlike snapping hip where a tight IT band snaps the greater trochanter area, with trochanteric bursitis, the IT band puts pressure on the bursa sac that lies underneath it. The inflammation of the bursa sac leads to hip pain.
• Femoroacetabular impingement (FAI): FAI is caused by bone overgrowth, or bone spurs, at the top of your femur, the femoral head or at the edge of the acetabulum, the hip socket. Where your femoral head meets with your pelvis at the hip joint and is covered by a tissue called articular cartilage and a strong fibrocartilage called the labrum. The overgrowth causes friction in your ball-and-socket joint leading to tears in the labrum and the breakdown of articular cartilage (osteoarthritis). Impingement occurs with certain movements and without treatment, long-term range-of-motion will be lost.
• SI joint: The sacroiliac joint (SI joint) is located below the lumbar spine and above the tailbone and acts a shock absorber. If there are muscle imbalances around the your SI joint, this can lead to hypermobility or hypomobility of the joint. If the joint is hypermobile, or moves too much and is not stable, you will feel pain in the lower back and hip. If the joint is hypomobile, or moves too little, you may feel pain in your buttock and down your leg and the sensation is similar to sciatica.
If some of these chronic conditions are left untreated, osteoarthritis can develop over time with continuous repeat damage to the cartilage and tendons surrounding the hip joint.
Acute Hip Pain
A sudden pain in the hip is usually the result of a direct physical injury to the hip. Falling or abnormal twisting the hip, among other injuries, can cause intense pain, bruising, or swelling. More severe symptoms of hip pain include:
• Inability to put weight on the hip
• Inability to move the hip in a normal manner
• Any acute injuries could result in fractures, inflammation, or injury to the tissues surrounding the hip.
Identifying The Cause Of Your Hip Pain
During your physical therapy evaluation, your physical therapist will review your medical history and gather specific details around your hip condition such as the location of the pain – can touch or deep within the joint – and when the pain started to occur. Based on your review, your physical therapist will use their hands to pinpoint the painful area. For example, if the pain is related to a muscular issue such as piriformis or snapping hips, they will look for tenderness in the internal hip flexor or external IT band, respectively.
Both manual therapy and guided exercises should be used together for the best treatment outcome. Due to the location of the hip, it is very difficult to do the self-mobilization techniques needed to give your hips full range-of-motion. With the help of your physical therapist, your treatment will begin with passive motions performed by your physical therapist to move your leg and hip and will progress to active exercises you can do at home.
• Manual therapy: Increase mobility and tissue healing of irritated structures around the hip which are preventing proper movement. By mobilizing your joints and stretching your joint capsule, your physical therapist will give your hip joint greater mobility and flexibility.
• Muscle mobilizations: Manual manipulations or glides (small and specific movements) stretch and strengthen the tissue around your hip joint. The goal is to restore the full range of your hips natural movement.
• Custom exercises: To strengthen the muscles that support and protect the hip, increase functional movement and decrease risk of further injury.
When Is Surgery Needed?
Hip surgery depends on the severity and type of the condition. For sudden injuries (i.e. torn cartilage or ligaments), surgery may be a better option to repair mechanical instability in the hip. In other cases, the injury may be inflammatory in which case surgery is less helpful. Those with chronic hip pain that severely impacts their day-to-day life can also consider hip replacement, which replaces the joint with an artificial joint. About 97% of hip replacements are due to hip fractures because of osteoarthritis. Depending on how far your osteoarthritis has progressed, surgery might be a better option in some cases. Other times, physical therapy for chronic hip pain can be just as effective at restoring movement and decreasing pain.
Whether undergoing surgery or not, managing the symptoms of hip pain with rest, pain relievers, and physical therapy is necessary. For most people, physical therapy is a good place to start their treatment course, especially if symptoms aren’t severe. Your physical therapist can refer you to an orthopedic surgeon if surgery is necessary for your condition.
When To Seek Help
If your hip pain affects your general mobility, gait or sleep, you should seek treatment as soon as possible to prevent potential inflammation from getting worse. When it comes to hip pain, it’s important to always consider that there are a wide range of symptoms. Determining whether or not you have acute or chronic pain and how impaired your range of motion is will help improve and optimize your treatment program. With or without a surgical procedure, incorporating physical therapy into the treatment of hip pain will result in quicker healing, less hip pain, and a reduced risk of future hip pain. The goal of treatment is to allow you to resume your everyday activities unrestricted by your hip pain.