Hip Pain: The Big Three

Hip Osteoarthritis, Hip Bursitis, Pyriformis Muscle Syndrome

Your hip significantly affects your daily activities. Hip pain can affect your walking, sitting and sleeping. For most people this affects every aspect of their daily lives. The following will help the reader understand their hip pain, the mechanisms why you have hip pain and how Kulp Physical Therapy and Massage can help you with your hip symptom.

So how does your hip pain start? You are 60 years old, you've raised your children and you’re considering retirement and your activity level has changed from being an active mother or father, raising your children, doing your household and work activities. You used to be involved in house renovations, painting or fixing a door and participated in recreational sports at work or at the club. Now you're more sedentary and you have periodically involved yourself in a walking program or a light exercise program, but that effort comes and goes and you find yourself 30 or 40 pounds heavier than you were. Then it happens, you wake up one morning from pain in your hip. You think to yourself, what did I do yesterday, did I strain myself, did I stumble when walking? Then as the week passes the symptom increases. You start taking a pain reliever and you read online that heat or ice is a good idea so you try that. You may even try a couple of stretches or exercises that you learned along the way or on the Internet, but this is not helping the pain. Another week or two goes by and your hip symptom is increasing and it is starting to affect the way you are walking and it keeps waking you up at night. Your hip is stiff when you wake up in the morning and you decide to call your doctor who prescribes pain medication. The pain starts going down from your hip into your thigh and you realize, “I've got a real problem”. This problem is replayed often throughout our community. It is no different for men or women whether you are 30, 40, 50 or 60 and it is a consistent issue that we see regularly at Kulp Physical Therapy and Massage.

There are so many diagnoses that can affect the hip. I counted 27 different diagnoses in one guideline article. (2) From osteoarthritis and other forms of arthritis, ligament laxity, hip strain, fractures, tendinitis, bursitis, hernias to referral from the low back. These are just some of the common differential diagnoses that can affect the hip. I picked three hip diagnoses that are representative of hip disorders that are most commonly seen here at Kulp Physical Therapy and Massage that you can identify with and use as a guide to decide if physical therapy can help your hip symptoms.

Let's start with Hip Osteoarthritis. Hip OA is the most common cause of hip pain in older adults, (3). The diagnosis of Hip OA has certain characteristics: joint space narrowing with radiographic features including osteophytes and subchondral sclerosis seen on x-rays, this is considered a definitive diagnosis. Individuals with Hip OA generally present with the following symptoms: Moderate pain in the lateral or anterior hip with weight-bearing. This symptom may refer to the anterior or lateral thigh region. Hip OA occurs in individuals older than 50 years of age and have limitations with passive motion in 2 of 6 directions, (internal rotation, external rotation, flexion, extension, abduction and adduction). People with Hip OA may also present with morning stiffness that improves in less than one hour.

Now let's look at and define Greater Trochanteric Hip Bursitis. Greater Trochanteric Hip Bursitis is simply the irritation of the Greater Trochanteric Bursa which is most frequently irritated by the friction of the shortened Iliotibial Band as it slides back and forth over lateral thigh during gait. This can occur from a weakened Gluteus Medius muscle, excessive pelvic displacement in horizontal plane from leg length discrepancies which again may be due to weakened Gluteus Medius muscle and/or running on an irregular or banked surface, (4). Individuals who have Greater Trochanteric Hip Bursitis generally present with a localized area of tenderness and pain near the superior – posterior tip of the Greater Trochanter, (the most prominent point of the lateral hip). This tenderness may make it difficult for the individual to lay on the affected bursa for prolonged periods, (when sleeping). In addition, they may present with a Trendelenburg gait which is characterized by lateral displacement of the hip when weight is put on the involved leg during walking or running.

Lastly, what is Pyriformis Muscle Syndrome? Pyriformis Muscle Syndrome is a condition where the Pyriformis Muscle, (see figure labeled Pyriformis Muscle), contributes to the entrapment or irritation of adjacent nerves, (Sciatic nerve). This usually happens when trauma occurs to the buttock or with repetitive internal rotation of the hip which can cause the strain in the Pyriformis, resulting in irritation of the hip joint, muscles or nerve. Common complaints for Pyriformis Muscle Syndrome include pain in the buttock which often refers posterior and inferior to the same thigh and occasionally to the calf. Pyriformis Muscle Syndrome also can occur from prolonged sitting on a thick wallet in one's back pocket called, “wallet sciatica”. Myofascial trigger points, (4) will be present and located in the mid-buttock and will result in localized and referred muscle pain and soreness. The individual may also experience overpronation, (flattening of the arch), of the same side foot during walking and running, (5).

The low back, knee and feet significantly influence mechanics of the hip. In addition, a person's posture will affect how the hip is positioned and moved. Kulp Physical Therapy and Massage will utilize movement impairment exercises to help strengthen the core and develop good movement patterns so that the lumbar spine and knee are moving properly. This will promote proper alignment during activities of standing, walking and climbing stairs. With each of these conditions of the hip, the individuals sleep can be affected. Kulp Physical Therapy and Massage will teach the individual correct sleeping or alternative sleeping positions to improve their restorative sleep. People don't think about the usage patterns that their bodies have gotten used to and have compensated to the type of activities they have been performing. Kulp Physical Therapy and Massage is promoting the concept of exercises that work on aligning the body, recruiting the right muscle groups and developing more precise movement patterns that will promote health while reducing arthritis, repetitive injury and pain.

The myofascial trigger point will be present in muscles around the hip, low back, thighs and lower legs in association with your hip diagnoses. Kulp Physical Therapy and Massage are specialists in the treatment of myofascial trigger points. Janet Travell found and documented the myofascial trigger point’s referral pattern of muscles throughout the hip. (1).

Note the referral patterns below.

Travell showed that the myofascial trigger point when active or latent will cause a loss of range of motion, weakness of the muscle, lack of coordination of the agonist and antagonist muscle movements, joint compression as well as neural compression.(1)

For Treatment of Pyriformis Muscle Syndrome, Treatment of the myofascial trigger point is at the front and center. Treatment includes manual trigger point compression, spray and stretch technique, manual stretching, myofascial stretching and passive stretching. Modalities of ultrasound and electrical stimulation, have shown effectiveness in reducing the myofascial trigger point. Kulp Physical Therapy and Massage will utilize exercises that will develop the right muscle recruitment patterns and then strengthen the muscles to promote correct alignment in the hip, back and knee joints. The result will be less muscular strain, muscle soreness and reduced myofascial trigger points. Kulp Physical Therapy and Massage will evaluate and treat each muscle, eliminating the trigger point and movement dysfunction.

When Greater Trochanteric Hip Bursitis is present, symptoms can be particularly difficult for the patient and requires a skilled approach to reduce the stressors on the tissues. First we start by educating the patient on what they're doing that is contributing to this dysfunction. Then we develop a low grade exercise program that moves the tissues without irritating them. Then we strengthen the hip joint complex and develop improved control through proprioceptive exercises. Kulp Physical Therapy and Massage will decrease inflammation and pain in the Bursa and surrounding tissues through the use of manual joint and tissue techniques, modalities of ultrasound and High Volt electrical stimulation, (including the use of phonophoresis and iontophoresis), and thermotherapy techniques. We will also work with the individual to ensure their footwear and orthotics are correct as not to create improper alignments that can lead to further hip pain and leg length asymmetries. Kulp Physical Therapy and Massage also promotes referrals to specialists in Orthopedics and Podiatry as well as utilizing the patient's Primary Care Physician in the care of their symptoms.

With the treatment of Hip OA, there are several imperative strategies; 1) Patient education and self-management of their arthritis. This includes educating the individual in understanding the importance of preserving their hip range of motion and muscle function and teaching the individual how to modify activities, exercise, with the emphasis in weight reduction and use of assistive devices as a method of unloading arthritic joints, (3). 2) When the Hip Joint OA is irritated, Kulp Physical Therapy and Massage will decrease inflammation and pain through the use of manual joint and soft tissue techniques. As noted earlier, modalities of ultrasound, electrical stimulation and thermotherapy techniques can help the individual with their acute and chronic symptoms. 3) Most importantly, Kulp Physical Therapy and Massage will develop a home exercise program that the patient will utilize to help themselves.

These three conditions of the hip are representative of the type of hip symptom that most individuals or their families can be affected by throughout their lives. We hope the descriptions for each diagnosis and the treatments that Kulp Physical Therapy and Massage utilizes were helpful. This does not represent the entirety of hip diagnoses and/or treatments they are just examples of how we would evaluate and treat a hip condition.

Kulp Physical Therapy and Massage has two nationally certified manual therapists. Take a few moments to inquire how Kulp Physical Therapy and Massage can help you. Please contact Doug or Janelle at 585-742-8270 or email us at kulptherapy@frontier.com if you’re interested in pursuing evaluation and treatment of your hip symptoms.

(1)Travell JG, Simons DG. Myofascial Pain and Dysfunction, The Trigger Point Manual, Vol. 1. Baltimore. Williams and Wilkins. 1993.

(2) Enseki K, Harris-Hayes M, White DM, et al. Non-Arthritic Hip Joint Pain. Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health from the Orthopedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2014; 44(6):A1-A32. doi:10.2519/jospt.2014.0302.

(3) CibulkaMT, White DM, Woehrle T, et al. Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health from the Orthopedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2009; 39(4):A1-A25. doi:10.2519/jospt.2009.0301.

(4)Malone TR, Mcpoil , Nitz AJ. Orthopedic and Sports Physical Therapy. Third edition. St. Louis. Mosby. 1997:498.

(5)Malone TR, Mcpoil , Nitz AJ. Orthopedic and Sports Physical Therapy. Third edition. St. Louis. Mosby. 1997:499.