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Hip Trochanteric bursitis

The trochanteric bursa is a small fluid filled sack which sits between the hip bone and the tendons of the muscles which attach on to it. Its role is to reduce friction as the muscles contract during movement of the hip.

The trochanteric bursa can become inflamed and irritated when certain muscles become excessively tight causing an uneven pull across the hip joint. This increases the amount of friction and causes a build-up of fluid in the bursa.

Common causes for the hip muscles becoming excessively tight include over activity or repetitive movements of the hip, muscle imbalance caused by poor supportive footwear, weakness in the hip muscles and inactivity over a duration of time. The bursa can also become irritated due stiffness in the hip joint itself.

People suffering with trochanteric bursitis of the hip will typically complain of localised pain over the side of the hip joint. The pain is made worse by walking, climbing stairs, getting in and out of the car and when trying to sleep on the affected side at night.

The aim with physiotherapy is to correct any imbalance in the hip muscles to prevent excessive friction on the bursa. Treatment normally entails soft tissue mobilisation to the tight hip muscles, stretches to the hip joint to improve mobility and local treatment to the bursa to reduce pain and inflammation. Occasionally it may be necessary to look at orthotic intervention (shoe insoles) if the foot is deemed to be the cause of the problem. Education and advice about activity modification is given to reduce irritation to the bursa during the course of the treatment. Exercises are given to improve flexibility in the hip muscles which have become tight and strengthen the weak muscles so the tendons pull more evenly across the joint.

Hip joint osteo-arthritis

This is better known as "wear and tear" of the hip joint. It is a slow degenerative process whereby the cartilage covering the surface of the hip joint slowly erodes away. This may have been caused by genetics, having played a lot of sport over a number of years or previous trauma to the hip joint. The surfaces of the bone are normally covered by cartilage which is smooth and slippery. This allows the joint surfaces to move freely over one another.

The hip is a ball and socket joint. The ball part is made from the end of the thigh bone (called the femoral head) and the socket is a round deep depression in the pelvis. As the cartilage is worn away the joint surfaces slide over one another less easily. Gradually more bone is laid down by the body causing irregularity to the femoral head and a reduction in joint space between the ball and socket.

People may notice a gradual reduction in mobility in the hip during daily activities such as putting shoes and socks on, sitting down and walking. It is not uncommon to get pain elsewhere in the body with osteo-arthritis in the hip such as pain in the lower back and knee. This is because the lack of movement in the hip can upset the mechanics of the back and knee placing more stress on these areas.

Pain arising from the hip joint may present in several places. Most commonly people complain of pain in the groin, outside of the hip and behind the hip joint in the buttock. The pain is normally described as a deep dull ache in the hip but can become a sudden sharp pain during twisting movements on the hip, sitting and standing up, walking and getting dressed when bringing the knee close to the chest.

Osteo-arthritis of the hip is diagnosed most accurately by X-Ray. The history of onset, age of the person, location of symptoms and assessment of the movement of the hip normally gives a fairly accurate picture as to whether the underlying cause for the hip pain is osteo-arthritis. Treatment with physiotherapy normally involves mobilisation to the hip joint to reduce stiffness and exercises to mobilise the hip and improve strength.

Hip impingement

This is a term used to describe pain arising from the hip joint due to a structure becoming pinched during movement of the hip. This causes pain due to inflammation of the structure becoming pinched (impinged). This can occur when there is not enough room within and around the joint to accommodate the tendons and other soft tissues as the hip is moved. Lack of movement in the hip can arise from soft tissue contracture following immobilisation of the hip joint which would occur if the leg was placed in plaster after a fracture to the thigh bone (the femur) or knee. Osteo-arthritic changes in the hip can also cause reduced movement as well as poor flexibility in the muscles around the hip restricting movement in the joint. Poor hip flexibility can occur through too much sitting in our daily lives and not moving our hips enough when we bend forwards thereby placing more strain on our lower backs.

One of the aims with physiotherapy is to re-educate movement patterns so people learn to move more through their hips during every day movements such as sitting, bending forwards and squatting down. Passive treatments such as mobilisations to the hip joint and soft tissue massage can help to improve hip range of movement. Exercises are also given to improve flexibility in the muscles which have become stiff and strengthen muscles which have become weak.

Hip impingement - Femoroacetabular Impingement

Another cause of hip impingement is a condition called femoroacetabular impingement or FAI. This is caused by a change in the shape of the bones which create the hip joint. This is different to osteo-arthritis and occurs in younger and more sporty/active people. Extra bone can build around the socket of the hip joint (called a pincer defect) or near the ball part of the joint (called a CAM defect). There can also be a combination of the pincer and CAM defects. This causes the bones in the hip to rub excessively during movements of the hip leading to inflammation of the joint lining (called synovitis) and tendons. Over time there can also be damage to the cartilage in the hip and ring which deepens the socket called the acetabular labrum.

FAI is difficult to diagnose as standard X-Rays appear normal. Provisional diagnosis is made upon the site of the patient's pain, activities/positions of the hip which trigger symptoms, history of onset and age of the patient. There are also orthopaedic tests which can be performed on the hip during examination which can help with diagnosis.

Typically the person with suspected FAI will describe a gradual onset of their symptoms. The pain is normally located deep in the groin and is described as a dull ache. People can also describe a "C" shaped pattern of pain around the hip. There may also be secondary symptoms in the buttock, pelvis and lower back. Symptoms tend to be aggravated by prolonged sitting, driving and impact exercise such as running or sports involving twisting like football.

If FAI is suspected a referral is made to an orthopaedic hip specialist for further investigation in the form of MRI arthrogram (an MRI scan performed after a dye is injected in the hip) and further X-Rays or CT scan. Treatment options can include steroid injection in the hip to provide temporary pain relief and key hole surgery. A lengthy period of physiotherapy is required following surgery to strengthen the hip and core stability muscles and re-educate movement.

Hip capsulitis

Hip capsulitis is a less common condition of the hip and occurs when the capsule of the hip contracts, thickens and becomes inflamed. It is not understood why the hip capsule begins to tighten. The hip may have been subjected to a trauma, repetitive strain or became tight for no obvious reason (insidious onset). People with capsulitis of the hip will notice a gradual decrease in range of movement of the hip and will complain of stiffness and pain when moving the hip into certain positions. There may be occasional clicking or "popping" felt deep in the hip joint as the hip is moved. Ideally, the person will have obtained an X-Ray of the hip to negate any other cause for the loss of movement such as would occur with osteo-arthritis.

Physiotherapy treatment involves passively stretching and mobilising the hip joint. Commonly a mobilisation belt is used by the therapist to achieve a localised stretch to the hip. Other local treatments such as soft tissue release, acupuncture and ultrasound can be helpful in calming down any inflammation in the hip and capsule. Exercises are taught to perform at home to improve range of movement and strengthen the hip.

Groin pain

Groin pain can be caused by local irritation or tendonitis to the muscles which attached into the groin region. The pain may also be secondary due to an underlying problem with the hip such as osteo-arthritis, capsulitis or femoroacetabular impingement. Groin pain may also be referred from the lower back.

Inflammation of the adductor tendons and deep rotators of the hip which insert into the groin can become inflamed due to overload placed on them. This can be due to biomechanical factors such as running with poor supportive shoes, over pronation of the feet (excessively flat footed) and weakness in the hip muscles.

Groin pain is common in sports involving kicking, twisting and running such as would occur in football. Poor strength in the stability muscles in the pelvis can cause the adductor muscles to become overloaded. The role of the core stability muscles are to hold the pelvis in the optimum position so that there is good anchorage for the muscles to pull from as they contract. Poor core stability leads to adverse movement in the pelvis as the muscles contract. This causes undue stress to be placed through the muscles in the leg leading to strain and injury.

For more information or to book an appointment please call 01322 275 402 or email info@westhillphysio.co.uk. Alternatively please feel free to complete the form below.
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