Conservative care for hip pain; Management with chiropractic care and therapeutic exercise

William Brightman DC, MS, MEd

Hip pain has become very common in this day and age. I see it in my office on a daily basis and it is not just the older population. From school age through adulthood, people are afflicted with hip pain. The causes of hip pain are vast and varied, but with many other musculoskeletal conditions, lifestyle influences the outcome. 
The hip joint is a basic ball and socket joint that is able to move in several planes of motion. The most common is flexion and extension- as what you would see with walking, sitting, climbing stairs, and exercises such as squats. When hips are in a flexed position for an extended period of time the hip flexor muscles shorten up. This shortening of hip flexors will cause stiffness- especially when trying to stand up- and eventually pain in the hips and possibly the low back. Over time this shortening of the hip flexors will impinge on the joints themselves causing further restrictions and more pain. Joint pain is different from muscle pain but when one structure is injured the other is undoubtedly influenced. 
There are other causes of hip pain that can come from structures around the hip and even from the low back. It is important to examine all the structures and see which ones are restricted or contributing to the pain. An orthopedic and neurological exam combined with specific palpation and testing individual muscles and joints can determine the cause of the problem. Palpation is a tool that has been largely overlooked in modern medicine because of advanced diagnostic testing, but can be a very valuable skill for the practitioner if they have kept on top of it. Palpation essentially means to clinically examine each anatomical structure with your hands identifying specific patterns of local or referred pain. I find it very effective in my office and have been able to diagnose problems that are overlooked.  
Ninety-five percent of the time the diagnosis can be made after the physical exam. However, sometimes it is necessary to take x rays to rule out any degenerative changes in the hip. Osteoarthritis of the hips leading to potential hip replacements is not uncommon and this surgery is not just happening to the elderly, but people who are considerably younger and in good overall health. Fortunately, the surgery is very successful if you are in need, but the goal is to avoid and prevent the hips from getting to the point of “bone on bone”. 
Some differential diagnoses of hip pain include the following: trochanteric bursitis; Iliotibial band (IT) syndrome; strain of hip abductors (muscles on the outside); hip adductors (muscles on the inside); hip extensors (muscles in the back of hip); hip joint restrictions; sacro-iliac syndrome; labral tears; osteoporosis and arthritis (osteo, rheumatoid, psoriatic). 
As a sports chiropractor I will manage the strains and joint restrictions and take care of any imbalances. The results with extremity and sacro-iliac manipulation are effective and when combined with a daily therapeutic stretch and a strengthening program, the results are very good. I will refer out to other specialists if I am suspicious of underlying problems. Blood work and advanced diagnostic imaging such as MRI’s or CT scans may be necessary.  Collaboration with orthopedists and rheumatologists along with physical therapists is not uncommon in managing hip problems. If the patient has rheumatoid arthritis or osteoporosis, manipulation is contraindicated, and other techniques must be used to help manage symptoms. 
Another problem that I have seen in my office is hip impingement or femoral acetabular impingement syndrome (FAI). I have seen a high prevalence of this with power athletes. Athletes engaged in high velocity movements and speed are most at risk, but anyone can be afflicted. A soccer player who is sprinting and kicking a ball at a high rate of speed is an example of someone who may develop FAI. The hip joint gets so locked up they lose the ability to move it like a ball and socket joint. In fact, they tend to lose a high percentage of internal rotation. This is not a popular motion but critical to have in order to  perform at a high level. Specific manipulation to the hip joint works very well to reduce symptoms and allow athletes to heal rapidly. In my opinion, manipulating the hip joint in several planes of motion combined with lengthening of the muscles is superior to any other approach at managing this syndrome.

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Manipulation to the hip region is effective at opening up joints and muscles that are restricted. (above left long axis manipulation and right soft tissue release)

Shock wave therapy to help break up muscle restrictions around the hip (on left targeted pulse to gluteal                                                                                 muscles and on right to the Iliotibial band down the lateral thigh)

Hip joint problems can be greatly managed through conservative care, awareness of posture (sitting for extended periods of time), and therapeutic exercises to keep joints mobile and muscles strong and long. Collaboration with other physicians is recommended if conservative care is not alleviating the symptoms. Sometimes, cortisone is needed to calm inflamed tissues, and surgery to repair or even replace a joint. Thankfully, most people can do better with some hands on care,  minor changes to the program, and a little guidance along the way.

Foam rollers and lacrosse balls can be used to release myofascial soft tissue restrictions. (The fascia is the                                                                                                             covering or saran wrap on outside of muscle) 

Therapeutic exercises for the hip:

Above shows different stretches for all the muscles that cross the hip joint. When performing a static stretch try and hold for at least 15 seconds for each pose. Two sets or to tolerance will go a long way in stretching the hip muscles. 

Strengthening exercise of the hip:

Lateral glide to help stabilize the pelvis (hits the hip abductors)

Hip flexion with therabands (note:bands are above knee: start on left and finish on right)

Hip abduction (open chain exercise to strengthen gluteus medius→ helps to support hip and stabilize pelvis)

Hip extension with therabands (open chain exercise to strengthen gluteus maximus which is powerful hip extension muscle)

Hip rotation exercise: Internal rotation of the hip joint is one of the first motions to go and it is important to try and activate that motion

Hip adduction: This will strengthen the hip adductors of the inner thigh

Great hip and spine stabilizer! Hip extension combined with opposite shoulder in extension (The “bird-dog”- try without resistance then progress with body band)

Glute bridge: great for hip extension and pelvic and low back stabilization

Progressive bridge on physioball



                        William Brightman DC, MS, MEd
                        Sports Chiropractor/Exercise Physiologist
                        Private Practice, Mahopac, NY
                        [email protected]