Master your Management of Hip Pain

7 min read. Posted in Hip/groin
Written by Dr Jahan Shiekhy info

Managing hip pain can be confusing because there can be overlapping drivers of pain and a variety of non-invasive treatment approaches. In this blog, we’ll cover a no-nonsense approach to manage hip pain based on the practical by expert physiotherapist, Jo Kemp.

After a thorough assessment, we should have a classification of the hip pain and the associated impairments. Armed with this understanding, we are ready to manage hip pain through a multifaceted approach including exercise, manual therapy, and education.

See a full walk-through of this management process by Jo Kemp in her Practical here.

 

Hip and trunk strengthening progressions

Exercise is the cornerstone treatment for hip pain, with an emphasis on strengthening local hip and trunk musculature. For hip strengthening, we will use strength/hypertrophy parameters, so 2-3 sets of 8-10 reps. Note that pain during and 24 hours after exercise is acceptable, however, it should not exceed a 3/10 on the Visual Analog Scale (1). Similarly, we progress exercises based on improvements in strength AND tolerance to the increased volume/load. For each exercise, the patient should work up to 3 sets of 8-10 reps with a max of 3/10 pain, before progressing to the next level of difficulty. For trunk strengthening, we are promoting endurance adaptations, so we will focus on 3 sets of 20-30 seconds.

Hip adductor strengthening

To strengthen the hip adductors, a basic starting point is performing side lying leg lifts for a 2-3 second hold, since this position is typically less provocative. This side lying leg lift can be progressed by adding external load. Once mastered we can progress to a standing version with a resistance band. The final progression will be the “Copenhagen plank”, initially using isometrics with a shorter lever arm, as Jo shows here:

Hip abductor strengthening

Just like with the hip adductors, hip abductor strengthening can be started on the floor to provoke less pain. We can start with a bridge with a resistance band around the knees, pushing them outwards at the top of the bridge. The next progression is performing resisted hip abduction in standing. Finally, the hip abductors can be strengthened in a functional manner with an exercise like a hip hike, possibly even adding load.

Hip extensor strengthening

A fundamental hip extensor exercise is the bridge (or hip thrust) with a weight placed over the pelvis. A benefit of beginning in supine is that we can add significant load to the glutes without irritating the hip, since we are using a smaller range of motion. We can also perform standing resisted hip extension, which requires more motor control, as seen here:

An excellent final stage is the single leg deadlift, which has the added benefit of challenging hip proprioception, a common deficit in patients with hip pain.

Hip flexor strengthening

The hip flexors are often “demonized” as being overactive and tight. However, many patients with hip pain often have weak and tight hip flexors. Many patients find that sensations of hip flexor tightness actually improve when we load the hip flexors through their full range of motion.

Our starting point for hip flexor strengthening is supine, in a reduced range of motion. We can then progress up to standing, which replicates the function of the hip flexor in the gait cycle, as seen here:

For athletes, Jo recommends eventually working up to a plank with hip extension, which is a high load isometric for the hip flexor of the supporting leg.

Trunk stabilization exercises

Trunk stabilization is unique in that we primarily want to improve endurance and isometric control. An excellent variation (that also challenges the hip abductors) is the side plank, starting from the knee and elbow. Other excellent trunk stabilization exercises include Pallof presses, chops and lifts, and front plank variations.

 

Functional retraining

Along with local strength and motor control, we also need to redevelop functional movement patterns like squatting and jumping. This is especially important for the unaffected hip, since it often becomes deconditioned after hip injury.

The simplest starting point is the squat in a relatively comfortable range of motion. This can be progressed by increasing the range of motion and the intensity of the exercise (e.g. by altering tempo, adding external load, etc.). Next we can progress to a single leg squat variant, such as the shrimp squat or the split squat.

For jumping, we can begin with small amplitude vertical hops with both legs. This can be progressed by changing directions (e.g. lateral hops) and with unilateral hopping.

For the full progression of functional movement training check out Jo’s Practical here.

 

Manual therapy

While exercise is the cornerstone of hip treatment, manual therapy can be helpful to reduce pain and restore range of motion.

Soft tissue mobilization

Patents tend to experience soreness and tightness in the hip flexors, adductors, and glutes, so these are prime targets for soft tissue mobilization. Here, Jo demonstrates a technique for mobilizing the psoas:

Joint mobilization

Joint mobilizations can be incredibly effective for restoring pain free range of motion, thus improving participation in rehab exercises. Here Jo demonstrates a posterior glide in sitting, which replicates the deep hip flexion position that creates that unpleasant anterior pinch feeling:

 

Patient education

As physiotherapists, we get to spend lots of time with our patients, which gives us a unique opportunity to educate them. As such, we should educate them about restoring physical activity, imaging findings, and other treatment options.

Restoring physical activity

Many patients decrease their physical activity levels in response to hip pain, so we have an excellent opportunity to guide them towards healthy levels of physical activity. The World Health Organization (WHO), recommends at least 150 minutes of cardio exercise and 2 sessions of strength training every week (2). Just like with our rehab exercises, we should remind patients that minor pain with exercise is safe to work through. Also, patients may need re-education on the positive role of exercise on joint health. Moderate levels of exercise not only do not damage joints, but actually promote optimal joint health (3).

Discussing imaging findings

Patients often arrive with imaging findings, but an incomplete understanding of how they play a role in their rehab process. Our role is to place those imaging findings in the context of research and their specific case. Some patients may get fixated on the idea that physical therapy is not “fixing” the root cause of their pain and thus is futile.

For those patients we need to educate them that degenerative changes seen on imaging do not mean that they are doomed to have hip pain. Research shows that the size and prevalence of hip morphology (e.g. Femoroacetabular impingement) as seen on imaging does not correlate to symptomatology (4). Of course, this doesn’t mean we should completely ignore imaging findings. Rather, we should remind patients that their imaging is only one part of the puzzle and that through rehab we can often adapt to those changes.

Injections and surgery

When analgesics and physical therapy alone fail to provide sufficient relief, patients explore options like cortisone injections and surgery. While injections can provide relief for some time, multiple injections can degrade cartilage (along with a host of other side effects), so patients should approach these with caution.

In some cases, surgery can be beneficial. As much as we should encourage patients to try a full “dose” of physiotherapy, we also have a responsibility to refer them to a surgeon when appropriate. And we can educate them on the rehab process for various surgeries, which helps inform their decisions and plan life appropriately.

 

Wrapping up

Optimal hip pain management comes down to a thorough assessment, a robust exercise program, manual therapy, and patient education. As physiotherapists, we have the opportunity to be with our patients through their full journey and help them make informed choices about their healthcare. And beyond their hip rehab journey, our guidance can help restore or even enhance a patient’s health status through physical activity.

For a full walk-through on how to master your management of hip pain, check out Jo Kemp’s Practical here.

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