The hips don’t lie – things I have learned about hip pain over the last 20 years
Updated: Apr 11, 2021
Zuzana Perraton, Sports Physiotherapist and PhD candidate
Over the last 20 years working as a physiotherapist I have met my share of people with hip pain. I have worked with older people with hip osteoarthritis, kids with growing-related pain and many athletes with hip pain and injuries. I want to share with you some of my experience of working as a physiotherapist with people with hip pain and summarise some of the latest research (including some from my research group and my own PhD) that may help you understand hip pain diagnosis and management.
Collectively, our knowledge of what causes hip pain, and how to help people with hip pain, has increased exponentially over the last ten to fifteen years. Let’s dive into some of the highlights and I promise to use the minimum amount of Latin and jargon. 😊
Hip pain is common during sport and exercise, particularly in sports that involve kicking and twisting (football and Karate, I’m looking at you). Depending on which part of the hip joint is affected you may experience hip pain in the front, side or back of the hip or in the groin. Sometimes hip pain can be caused by strain to muscles or tendons (the connections between muscle and bone). Hip pain due to osteoarthritis is more common in people over the age of 45. Occasionally, hip pain can be a result of a stress reaction, or stress fracture, of the pelvic or thigh bones. A physiotherapist or other health professional will perform an interview and a physical examination to help diagnose the cause of hip pain and make a rehabilitation plan. I’m going to focus here on pain caused by the hip joint.
A common cause of hip pain is femoroacetabular impingement, or FAI. The Warwick Agreement, an international peer-reviewed consensus statement by experts in the field of hip pain defines FAI as “… a motion-related clinical disorder of the hip with a triad of symptoms, clinical signs and imaging findings. It represents symptomatic premature contact between the proximal femur and the acetabulum.”(1). This is a nice definition, but I think we should break this down into everyday speak…
The hip is a ball and socket joint where the ball (or top of the femur/thigh bone) sits within a socket (the acetabulum) in the side of the pelvis or hip bones. As the statement above says, FAI occurs when you get premature contact between the femur and the edge of the hip joint socket. Contact between the femur and the hip joint socket happens normally when you bend your hip up as far as it goes towards your chest, but people with FAI experience this contact earlier because of the shape of their hip joint. Over time with repetitive kicking and twisting activity there is a build up of bone on the neck of the femur near the hip joint socket. Over time the hip joint can become painful and can take a number of months to settle down. Over time, the additional bony growth can restrict hip movement and cause further pain.
Femoroacetabular impingement is diagnosed using both x-ray and clinical examination. Some people have anatomical changes on x-ray but do not have hip pain and therefore do not have FAI. Imaging studies show that anatomical changes to bony morphology on x-ray may be normal in some asymptomatic individuals and more prevalent in some athletic populations e.g. ice hockey and soccer players.(2, 3) Some researchers believe that bony changes around the hip joint, in the absence of pain, may be normal and reflect bone adaption in response to load. This may be particularly true while bony growth plates are still open in the growing athlete.
There is also some discussion amongst researchers that FAI may be a precursor to hip osteoarthritis and therefore early effective management of the hip pain, such as improving strength around the hip joint, can have a huge impact on an individual’s future joint health. My PhD research is investigating factors such as muscle strength that are associated with poor outcomes in people with FAI – watch this space!
In the last decade, arthroscopy (keyhole surgery) has been increasingly used to improve pain and function in athletes with FAI. A systematic review led by a colleague of mine at La Trobe university, Dr Joanne Kemp, found that hip arthroscopy can reduce pain and improve function in people with FAI. (4) However, there is still a lot to learn about the long term effectiveness of surgery for FAI. Most people with FAI will not have surgery; therefore, more research is needed to determine the effectiveness of exercise and education for FAI. These studies are currently underway around the world so expect an increased growth in publications in this area in years to come.
Stay tuned for a future blog to read about rehabilitation for hip pain.
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Griffin D, Dickenson E, O'donnell J, Awan T, Beck M, Clohisy J, et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. Br J Sports Med. 2016;50(19):1169-76.
Mascarenhas VV, Rego P, Dantas P, Morais F, McWilliams J, Collado D, et al. Imaging prevalence of femoroacetabular impingement in symptomatic patients, athletes, and asymptomatic individuals: A systematic review. European Journal of Radiology.85(1):73-95.
Frank JM, Harris JD, Erickson BJ, Slikker W, Bush-Joseph CA, Salata MJ, et al. Prevalence of femoroacetabular impingement imaging findings in asymptomatic volunteers: a systematic review. Arthroscopy. 2015;31(6):1199-204.
Kemp JL, Collins NJ, Makdissi M, Schache AG, Machotka Z, Crossley K. Hip arthroscopy for intra-articular pathology: a systematic review of outcomes with and without femoral osteoplasty. Br J Sports Med. 2012;46(9):632-43.