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Hip Pain

"Hip pain" can mean an awful lot of things. What exactly is the hip? In anatomy class, the hip is a joint more appropriately called the femoroacetabular joint (FA). A big ball and socket joint between the femur and the pelvis, the FA joint allows a great deal of motion but unlike the shoulder (the other big ball and socket joint) the FA joint is deep which does restrict range of motion some, but more importantly, gives us stability. Could you imagine if our hips dislocated as often as our shoulders do? It would be bad news.

Unfortunately, as is often the case with lay terminology, "hip" can also mean: the glutes, the iliac crest, the greater trochanter, the hip flexors, cool, etc. I'm going to talk about most of these along with problems of the FA joint itself as described above.

Vernacular aside, hip pain a is very common complaint in the chiropractic office. It has been my experience that there are two main categories of hip pain. 1) Hip pain coming from the FA joint and surrounding anatomy and 2) Hip pain coming from the low back. Either way, diagnosis and treatment is typically straightforward and the prognosis good.

Young man in casual office shirt having hip pain (Selective Focus).jpg

Anatomy of the Hip

The hip proper is made up of a large and deep ball-and-socket type joint aptly named the femoroacetabular (FA) joint. The joint between the head of the femur and the corresponding acetabulum of the pelvis is strong, stable and yet allows a great deal of motion in all planes. The joint surface is coated with durable cartilage like most joints. There is a labrum running around the circumference which adds some extra stability. The entire joint in covered in a fibrocartilaginous capsule which is then surrounded by some very robust ligaments. Finally the joint is crossed by several muscles which provide the movements that allow us to move.

The FemoroAcetabular Joint

A ball-and-socket joint, the FA takes most of our weight during ambulation (walking / running / etc). It is, therefore, prone to arthritis and a common site for surgical repair or replacement in our old age. The joint allows for motion in all six planes including circumduction. A condition called femoroacetabular Impingement may occur in individuals, often with little to no cause other than genetics. The joint surface is coated in hyaline cartilage which has a limited ability to repair as we age. There is also a bit of fluid within the joint to lubricate the surfaces as they glide.

The Labrum and Capsule

Around the circumference of the acetabulum there is a cartilaginous labrum which is flexible but provides stability to the joint. You would not want to have frequent hip dislocations which are very painful and difficult to reduce. Labral tears in the hip are quite common with injuries involving the hip and can range from minor to needing surgical repair. Like most things in our bodies, the hip joint in encapsulated by a bit of fibrocartilage that keeps everything protected and in place.

Muscle and Ligament attachments

Starting with the ligaments, we have some very robust ones that provide a lot of stability to the FA joint. The Y-Ligament or iliofemoral ligament is vary large and covers most of the anterior surface of the hip which is important because the acetabulum faces anteriorly and this is where we need that added stability most. There are numerous muscles that attach to the hip. For the sake of simplicity I am going to talk about most of them in groups. The one everybody talks about are the hip flexors (Rectus femoris & Psoas are the two main characters here). This is a problem area that is prone to injury and chronic shortening from prolonged sitting. Next up are the hip adductors which are also very strong but somewhat less prone to injury. The hip abductors are especially prone to weakness and dysfunction and often contribute to iliotibial band syndrome, are affected by pinched nerves in the back or are subject to tendinopathy. Hip extensors (hamstrings and glutes) are a common site for sciatica and injury (particularly in athletes). There are a bunch of smaller muscles attaching to the hip but the most clinically important of those is the piriformis which has its own syndrome named after it. Piriformis syndrome is also referred to as pseudo sciatica producing nerve pain down the posterior leg from compression of the sciatic nerve as it passed underneath (or sometime partially through) the muscle.

Iliotibial band (IT)

The IT band is a common offender in the chiropractic clinic. It is often referred to as IT band syndrome because it may manifest as multiple problems (hip pain, bursitis, knee pain, pseudo-nerve pain). The IT band attaches to the pelvis via the glutes and a little muscle called the tensor fascia lata and to the knee laterally. The fibrous band is stretched along the lateral thigh to assist in abduction some but mostly to keep things supported between the hip and knee as we walk/run. 

Bursae

Bursae are located all over the body and serve to lessen friction between moving parts. As you might imagine most are in the shoulders and hips (lots of moving parts there). There are two important bursae about the hip. One lays between the greater trochanter and the IT band aptly called the trochanteric bursa which, when inflamed, produces a sharp pain at the lateral point of the hip often making side sleeping impossible. The other big one in the iliopectineal bursa which lies in the front / anterior hip between the psoas and the pubis.

Nerves

Lumbar spinal nerves supply all of the muscles of the body from the waist down, including, for the sake of our current topic, the hip. Therefore, a problem in the low back may and often does manifest as problems in the hip. The sciatic nerve (what most of the lumbar spinal nerves become) runs down posterior glutes into the hamstrings and finally down the calf. Its a big one and a constant adversary for me in the clinic in the form of sciatica which is usually caused by disc bulges in the lower lumbar spine. The other prominent nerve, at least clinically is the lateral femoral cutaneous nerve which often gets pinched in the front of the hip during times of rapid weight gain (pregnancy for example) causing a numbness in the front of the thigh that is usually self limiting.

Inguinal region

This is the front part of the hip right at the crease. A bunch of big nerves and vessels run through this area. This is one of the most common areas for hernias to form protruding out of anatomically weak areas in the abdominal wall. Psoas pain and iliopectineal bursitis generally produce pain in this area.

bone and ligament anatomy of the hip often seen at normal chiropractic
muscles of the hip as seen at normal chiropractic
iliotibial band syndrome often seen by our chiropractor  Dr Malone
bursitis of the hip is often seen at normal chiropractic

Treatments for Hip Pain

If you have been carefully reading above, you will by now recognize that hip pain is rarely just hip pain. It depends, really, on which tissues are producing the pain and which are involved in the dysfunction or injury as to which treatments may be most beneficial. Lets discuss a few options and their strengths.

Chiropractic care:

If, as is often the case, the hip pain is stemming from the low back, joint manipulation of the lumbosacral spine is indicated and the prognosis is generally very good. Although healing may take time, patients generally respond very well to chiropractic care of the low back. Joint manipulation of the hip joint (femoroacetabular joint or FA) is relatively common. The FA joint is not the same type of synovial joint that we have in our knuckles or spine and does not cavitate (or crack) in the same way. Patients often feel a stretch and a clunk as the femur resets in the acetabulum. 

Soft-Tissue:

Addressing the soft-tissues (muscles, tendons) of the hip with manual techniques like myofascial release is generally effective in treating many hip conditions and imbalances. Exactly how is kind of a mystery, but we know that soft-tissue work generally stimulates a healing response in and round the tissues worked on. Depending on the genesis of the hip pain and the tissues involved, soft-tissue techniques applied to the muscles and tendons is often indicated even if some of the problems are secondary to a spine or other condition. It can be uncomfortable to have deep tissue work done around the hip but it is often really effective and the side-effects are minimal.

Electrical muscle stimulation:

EMS or TENS is an effective way to reduce muscle spasm and inflammation. It is not going to cure you but it often makes a huge difference in people's pain levels and improves function. The latter is a quality that helps people to use and exercise the hip which is vitally important to healing

Acupuncture:

Acupuncture has been around forever. Well not forever, but a really long time (3000 + years) as best we can tell. There are many forms of acupuncture and some have been shown to be more effective for different conditions. In the hip, modern acupuncture (needling the structures involved) and dry needling have been shown to be very effective for many hip conditions, especially those which affect the muscles around the hip. Again, it is important to identify the root of the problem as to not chase symptoms and neglect that actual cause of the hip problem. Acupuncture at the clinic always follows a detailed exam and diagnosis so you can rest assured we are delivering the best possible care for your specific problem.

Physical therapy:

There is abundant evidence that physical therapy is an effective treatment for many (if not all) hip conditions. We strongly recommend PT for the hip. PT is best delivered by a professional. We often make referrals to PT for hip conditions. While the Chiropractor cannot, strictly speaking, deliver physical therapy, therapeutic exercise is often prescribed to help our patients recover from hip problems.

Other treatments:

As above, surgery, injections, medications are valid treatments for hip pain. While not natural or conservative, they have become the norm in a modern society. There is a time and place for invasive measures. Two factors go into that decision: 1) How bad in the injury? and 2) Will the injury heal appropriately without it. Often times the determining factor is who patients choose as their first provider. For example, people that go to a chiropractor or physical therapist are significantly less likely to have surgery. My advice is be patient and follow that proper channels before receiving invasive care.

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