A large number of people suffer from hip pain. Our work in our osteopathic and rehabilitation Cambridge clinic, working with a vast range of physical capabilities, and our athlete work in London, allows us to have very positive contact with such symptom sufferers. This is why we are some of the best osteopaths in Cambridge.
In fact, hip pain (including osteoarthritis, greater trochanteric pain syndrome and groin strain) is currently a common musculoskeletal illness, and the burden is most likely underestimated. Musculoskeletal illnesses are believed to generate some of the highest costs to society. Hip pain seems to have large effects on disability levels, quality of life and affects employment.
Some of the most commonly ‘diagnosed’ issues leading to an episode (acute), or multiple episodes (chronic), of hip pain, with or without ‘swelling’ (filling of the hip joint and capsule or fluid around the joint area) are:- Functional hip instability, structural hip instability, ‘piriformis syndrome’, femoro-acetabular impingement (FAI), femoral acetabular impingement syndrome, strain, motor control imbalances, tendonitis, ligament sprain, muscle strains, muscle spasms, over use syndromes, degeneration, arthritis, cartilage injury, ‘bursitis’, ‘trochanteric bursitis’, ‘inflammation’, ‘hip pain’, acetabular labrum tear, ‘subluxed hip’, ‘wear and tear’, ‘anterior hip pain’, ‘posterior hip pain’, mechanical hip pain, hip stiffness, hip swelling, fluid on the hip, ‘internal snapping hip’, ‘external snapping hip’, ‘iliopsoas tendonitis’, capsular laxity, ‘chondral damage’, labral tear, ‘ligamentum teres’, iliotibial band, gluteal tendon, ‘adductor strain’, groin strain, ‘sports hernia’ (gilmore’s groin), ‘athletic pubalgia’, ‘pubalgia’, ‘osteitis pubis’, femoro-acetabular arthritis, ‘great trochanteric pain syndrome.….The list goes on!
The quality of some of these diagnosis concepts, and the actual correlation to your pain, are even more fascinating!
How This May Affect People
When this doesn’t go well, it often leads to a very dissatisfying outcome. This can manifest itself as: deconditioning, disability development, depression, loss of confidence in yourself and your body, which ultimately often leads to a dependency on pain altering medications, and poorer physical health.
So, what are we to do? Are we to:- be immobile?, be mobile?, be active?, or minimally active?, train into pain (‘no pain no gain’)?, or train avoiding pain?, stretch the hip?, or no stretching of the hip?, use medication management?, topical or oral?, use massage?, use mobilisation?, Osteopathy or chiropractic or physiotherapy?, use prescriptive exercise?, regular treatments or minimal treatments?, have imaging or not to have imaging?, surgery?, should we focus on structure or function?, or is it just age?!!!
I have seen many osteopaths and physiotherapists about my hip and groin pain for many years, in Germany as well as in Cambridge, and I must say I have never met anyone as competent and knowledgeable as Michael Parr from Elementary Health. He does not just do his job, his heart is in his work. He goes to seminars, talks and workshops around the world and he is really engaged and committed whilst treating me. What I am most impressed by is how thoroughly he does the exercises with me. Nothing escapes his expert eye and he pays attention to the smallest movement and muscle, checking and ensuring that I do my exercises correctly; just like the best therapist I could imagine. With his great sense of humour, his friendliness, his sensitivity and good manners he makes sure that I never feel self-conscious when doing the exercises in front of him, and his correcting/adjusting/demonstrating feels very skilful and professional. Michael is also a really good listener, and in combination with his holistic approach he looks at the whole person. No one else before listened (and remembered!) so carefully to the details of my everyday life-style, how much a day I walk, how I carry my bag, which shoes I wear and all the other little things which contribute to orthopaedic issues and are far too often ignored by other therapists. On a practical note, I really like the fact that you can book your appointments with Michael online, receive reminder emails, that you can pay by card and email Michael any time.
Our understanding of the hip and its associated structures, is still changing and evolving.
Sometimes additional investigations are needed. However, for ‘non-specific hip pain’, they are rarely needed as a primary input into your assessment and treatment.
Imaging was originally seen by most, as a tool to rule out pathology or disease states, and less to diagnose specific musculoskeletal causes. Often this was due to a poor correlation of images and symptoms. New imaging approaches have developed, and our dependency on them has increased!
However, recent studies show that by performing a thorough clinical case history and physical examination you can often, very effectively decide if MRI or additional imaging or other investigations are needed.
There are also recent studies that show that MR Imaging (MRI), may actually increase the patient’s likelihood of continuing in pain or disability status, and elongate their symptom picture.
Then there are studies showing that degeneration changes, are just a part of function and use. These however, have no correlation with pain, or perceptions of illness, or illness behaviour i.e. age and degenerative changes have no clear causal link with pain.
Studies assessing images of the hip, seems to show ‘inconsistent association’ between ‘radiographic’ and ‘clinical’ osteoarthritis. This maybe also due to the lack of association between hip pain, and radiographic evidence of hip osteoarthritis. Where studies show hip pain was not present in many hips with radiographic osteoarthritis.
Assessment using, MRI, CT scan, ultrasound, for the hip joints, are only used to complement the clinical history and physical examination when required, as it will need ‘clinical correlation’ and ‘interpretation’, to help ‘categorisation’ and trends.
This sometimes helps rule out, some of the ‘diagnosis’ that are referred to perhaps a little too commonly, and sometimes helps support the clinician diagnosis, from presentation and examination. One of the best examples for this is athlete groin pain, and pubic aponeurosis injury.
Additionally, there is a very present discrepancy, in one third of cases, between ‘clinical’ and ‘radiological findings’, for ‘injury location’. This opens up the discussion about what is the injury. That which is on the image, or what is clinically found.
There seems to be some indications that gene – environment interactions have a role in Hip osteoarthritis development. Which means, how you use your genetics and hip, from childhood to adulthood, define the shape of the joint and local structures, and can contribute to the progression of changes.
However, conversely the shape of the hip may also alter, as a result of joint changes. This perhaps indicates that it is how you use yourself (function), that will define your hip shape and changes that occur (structure).
Additionally, similar structural hip shapes, perhaps developed by function of the hip, have association with other forms of hip pain, such as ‘greater trochanteric pain syndrome’. These may also be more prevalent in women.
Certain sports, have ‘sports specific’ injuries (sports common injuries), such as groin strain (groin injuries) in football players. However, like most mechanical issues, the true diagnosis, is still open to question, as many diagnosis terms are organised differently, in each study and clinic.
The most important thing to take from this, is that there are multiple causes to hip pain, beyond that of just osteoarthritis. These pains maybe due to the function of the hip. Many of the presenting issues can be effectively evaluated in clinic, without the need of an image.
What Can Help
Treatment by an osteopath has been shown by research data, to allow for positive outcomes and satisfaction levels.
Exercise therapy has been shown in research to reduce hip pain symptoms, and help restore normal daily activity.
Manual therapy, such as manipulative therapy, performed by an osteopath or physiotherapist, on the leg (lower extremity), including the hip, with conditions such as hip osteoarthritis, has been found to help.
There are interesting hints, in some research papers, that manual therapy alone, performed by a therapist such as an osteopath, maybe more effective than exercise alone.
Exercise therapy, such as dynamic exercise therapy, performed on land, not in water, has clear evidence that it assists in reducing pain, with significant increased quality of life and improved physical function.
These exercise programmes for the treatment and rehabilitation of hip osteoarthritis, can be achieved within 3 months.
Additionally, it is worth noting, the very important positive, that there is a very low level of reported adverse events, such as pain increase or irritation.
Then such therapies of therapeutic exercise and manual therapy, can be combined, for the treatment of many hip pain causes, including conditions diagnosed as osteoarthritis of the hip.
Certain hip related conditions such as iliotibial band syndrome, obtain interesting advice from many, and stretching is a far too common suggestion for sports performance, injury prevention and recovery. This however has no evidence of being effective.
In fact, there is now a Cochrane review assessing studies, clearly showing that stretching does not have a positive effect on joint motion and muscle contracture. Additionally, there are no known benefits to stretching, in regard to delayed onset muscle soreness in healthy adults. regardless of when these are performed.
In sports which have high prevalence of hip impingement, when they have maintained hip muscle strength: the passive hip range of motion, sports performance, and functional use of the hip, show no impairments. Perhaps indicating a need to keep hip muscle strength.
It is often possible to manage many hip issues, without surgery, with high satisfaction levels and improvements in function.
However, in cases where surgery has already been performed, including complete (total) hip replacement. Exercise and manual therapy have been shown to be effective at assisting with rehabilitation. Perhaps these are indicated to be performed for up to a year after the surgery.
Whole Body Integration
Then we can start to look at a more global pattern, and treatment plan.
Greater trochanteric pain syndrome (GTPS) is more common in women, and adults who have iliotibial tract pain, or knee arthritis. Indicating ‘altered lower limb biomechanics may be related to greater trochanteric pain syndrome’. However, leg length discrepancy has no evidence of association with greater trochanteric pain syndrome. Perhaps indicating that it is the functional integration of the whole body, which matters more than the structural presence of limb disparity.
Groin pain has been shown to positively improve, in relation to pain and return to sports, more effectively than only having passive physiotherapy treatments alone. When exercise therapy involved strengthening the abdominal muscles, as well as the hip muscles.
This may show why whole body assessment and treatment, is reported anecdotally to be so effective in clinic.
These positive effects from manual therapy and exercise, may be due to the increasing body of evidence, that pain is a brain interpretation of data, and the local structure itself, cannot be consistently linked with pain or general function.
Additionally, manual therapy by an osteopath including the use mobilization and manipulation, and prescription exercise therapy, are all safer than long, or even short term medication treatments, such as non-steroidal anti-inflammatory drugs (NSAIDs).
The point here is that there are many opinions and many solutions, to hip pain (femoro-acetabular pain). Perhaps some, in our opinion, are more rational than others and some statistically safer than others, and some more empowering than others.
With all treatments, it’s important to get the diagnosis, advice, and treatment programme from people who are trained, skilled and prepared to aid your musculoskeletal needs.
The guidelines for ‘hip pain’, includes the guidance to remain as active as normal, seek support and advice at a specialist clinic, for education, management advice, manual therapy including mobilisation and manipulation, mobilisation and soft tissue treatment, hydrotherapy application, increase in muscle strength and specialist exercise therapyfor rehabilitation.
At Elementary Health we provide a seamlessly layered combination approach, of education and therapeutic application. This includes education of anatomy and pain theories, manual therapy, osteopathy (Osteopaths Cambridge), posture advice and training, lifestyle advice, hydrotherapy guidance, dietary overviews, and dynamic exercise therapy with motor control training rehabilitation. All of these work together to provide a uniquely structured approach, towards the aim of restoring your brain’s interpretation, or ‘mapping’ of your healthy functioning body, giving you back the control!
If there are any other questions, or, you wish to book a consultation with Michael Parr the consulting osteopath in Cambridge, based at Elementary Health. Please don’t hesitate to call or email.