Physical therapy for hip pain
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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The hip is a "ball and socket" joint formed by the pelvis and the top of the femur.
Information from the American Physical Therapy Association
Both bones are covered with a smooth layer of protective cartilage. Loss of this cartilage from wear and tear, inflammation, or injury leads to arthritis.
The hip joint and the large muscles that cover it are protected by "bursae" (cushions) and lubricated by synovial fluid contained in the hip joint. Each bursa is a sack that contains lubricating fluid and functions to reduce pressure and friction around the joint. These bursa sacks can become irritated from injury, excessive pressure, and overuse. Inflammation of a bursa is called bursitis.
The hip has three major muscle groups responsible for motion:
The gluteals (buttocks muscles). Movements that involve use of the gluteals include stair climbing, getting out of a chair, squatting, leg extensions, stair stepper, swimming, and rowing.
The hip flexors (iliopsoas) flex the hip forward. Movements that involve use of the hip flexors include stair climbing, squatting, leg lifts, stair stepper, swimming, rowing.
The hip adductors, located in the groin and inner thigh, pull the hip inward.
Overuse and irritation of these muscles is called muscle strain. The most common muscle group to become strained is the adductor muscles (seen most commonly in sprinters and distance runners).
The major nerves controlling lower leg function cross the hip. Irritation of these nerves can cause pain into the hip and down the leg. Injury to the sciatic nerve frequently causes pain along the outer thigh or down the back of the leg (sciatica). Injury to a smaller nerve in the groin, the lateral femoral cutaneous nerve, can cause pain and numbness in the outer thigh, a disorder known as meralgia paresthetica.
Bursitis is the most common cause of hip pain; arthritis is second most common. Tendonitis also occurs.
Physical therapy is helpful for the treatment, rehabilitation, and prevention of many of the conditions that affect the hip and its surrounding supporting structures.
Physical therapy of the hip may include any or all of the following:
• Muscle toning exercises
Heat helps prepare the tissues for stretching and should be performed prior to exercise sessions. The preferable method of heating is in a warm shower or bath for 10 to 15 minutes. Local heat (for example with a moist heating pad or a towel warmed in a microwave) is an alternative, but generally not as effective.
Stretching exercises should be performed daily in people with hip arthritis or bursitis.
Do not perform these exercises until you've checked with your physician or physical therapist
The stretching exercises appropriate for people with arthritis of the hip include knee-chest pulls, the figure-four stretch, and the Indian sitting stretch. These are performed in sets of 15 to 20 after heating.
• To perform knee-chest pulls, bend the hip and knee to 90 degrees. Grasp the upper shin and pull the knee onto the chest. Hold this position for 5 seconds and then relax back to 90 degrees. Perform these lying down.
• To perform the figure-four stretch, the foot is placed along side the knee. The leg is gently rocked outward. The higher the foot is raised the greater the stretch.
• To perform the Indian sitting stretch, pull the feet up toward the buttocks while in a seated position on the floor. Lean forward gradually to increase the stretch in the groin.
The stretching exercises appropriate for people with bursitis of the hip include cross leg pulls and outer thigh stretches.
• To perform cross leg pulls, cross the affected leg over the other while in a sitting position either in a chair or on the floor. Grasp the knee and pull the leg to the opposite side. Keep the buttocks flat; do not roll the pelvis. A gentle pulling sensation should be felt in the outer buttocks or hip area. Sharp pain suggests irritation of the bursa.
• To perform outer thigh stretches, stand an arms length away from a wall with the affected leg toward the wall. Cross the affected leg behind the other leg. Carry all the weight on the good side. Lean into the wall, stretching the entire leg and lower side muscles.
Ultrasound treatments may be prescribed for people who have recurrent or chronic bursitis. This is performed by a physical therapist or chiropractor. Ultrasound serves to heat the deep tissues about the hip.
Muscle toning exercises are helpful for special occasions. They are typically recommended when deconditioning has occurred as a result of prolonged bedrest, cast immobilization, or lengthy inactivity. Toning exercises should always be preceded by stretching exercises.
• Straight leg raises (strengthening the hip flexors) are performed while sitting on the edge of a chair or while lying down with the opposite leg bent. The leg is raised 3 to 4 inches off the ground. Sets of 15 to 20 leg raises, each held 5 seconds, are performed daily. With improved strength, these exercises are performed with a 5 to 10 pound weight placed at the ankle.
• Leg extensions (strengthening the gluteals) are performed while lying on the stomach or while up on all fours. The leg is raised perfectly straight, 3 to 4 inches off the ground. Sets of 15 to 20 extensions, each held 5 seconds, are performed daily. After 3 to 4 weeks the exercise is performed with low amounts of weight added to the ankle. This exercise must be performed flat if there is knee cap irritation or arthritis.
The following positions and activities are safest and reduce the possibility of re injury to the hip joint and the surrounding bursae:
• Sitting in a partially reclined position
• Sitting up straight with the leg turned out
• Standing with the weight equally distributed between the right and left legs
• Lifting and carrying weight close to the body
• Sleeping on the back with the legs spread apart
• Sleeping on the unaffected side with a large pillow between the knees
• Keeping weight down
• Low weight, high repetition weight lifting
• Swimming with the crawl kick (legs kept straight)
• Using a cross country ski machine with low tension
Patients with hip arthritis should avoid the extremes of hip motion and should minimize high impact activities:
• Contact sports such as football, rugby, and wrestling, and the "stop-and-go" sports such as basketball, tennis, and racquetball are poorly tolerated. The rapid changes in position and/or the impact and jarring of these activities can accelerate arthritic damage.
• Avoid running and jumping
• Avoid positions that cause wide spreading of the legs
Repetitious bending of the hip should be avoided, as should direct pressure over the hip.
• Do not sleep on the affected side; sleeping on the back or stomach is preferable.
• Stair climbing, stair stepper, step aerobics, rowing machine, bicycling, squatting, and the "stop and go" sports such as tennis and racquetball create too much friction and irritation and should be avoided until the pain has long subsided.
• Avoid prolonged sitting with the hip in a bent position.
• Minimize working in a stooped position.
• Limit repetitive bending at the hip.
• Do not bend over to touch the toes .
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