Hip Pain and Mobility Deficits

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Introduction

Hip joint pain is a common clinical problem that can be seen in adulthood at any age or activity level. The purpose of this page is to describe the evidence-based physical therapy practice including diagnosis, assessment and interventions for hip pain in adults.

Hip pain can arise for a variety of reasons, most commonly caused by hip osteoarthritis (OA). Non-arthritic hip joint pain can arise due to the conditions such as femoroacetabular impingement syndrome (FAIS), developmental dysplasia of the hip (DDH), hip instability, acetabular labral tears, osteochondral lesions, loose bodies, and ligamentum teres tears.

Clinically Relevant Anatomy

Anterior view of the right hip joint.

Aetiology

Possible causes of hip joint pain according to the common pain locations are:

Anterior Hip Pain

• Referred pain: From intra-abdominal or intrapelvic causes
• Extra-articular: Flexor tendon
• Intra-articular: Femoroacetabular impingement, labral tear, femoral neck stress fracture, avascular necrosis, osteoarthritis, hip fracture

Lateral Hip Pain

• Greater trochanteric pain syndrome, including bursitis, gluteus medius tendinopathy or tear, external snapping, or iliotibial band friction

Posterior Hip Pain

• Referred pain: From intra-abdominal or intrapelvic causes
• Deep gluteal syndrome
• Ischiofemoral impingement
• Lumbar spine or muscle
• Sacroiliac joint pain
• Proximal hamstring tendinopathy or tear

Mechanism of Injury / Pathological Process

Clinical Presentation

Hip pain can can be located anteriorly, laterally, or posteriorly.

Diagnostic Procedures

Moderate anterior or lateral hip pain during weight-bearing activities, morning stiffness less than 1 hour in duration after wakening, hip internal rotation range of motion less than 24° or internal rotation and hip flexion 15° less than the nonpainful side, and/or increased hip pain associated with passive hip internal rotation. (Grade: A)

Risk Factors

Clinicians should consider the following as risk factors for hip osteoarthritis:

• Age over 50 years
• Hip developmental disorders
• History of previous hip injury (Grade: A)

Risk factors of hip osteoarthritis (OA) include being overweight or obesity, joint injury and increasing in age. At present, there is currently no cure for OA, but there are many treatments and approaches to managing the long-term symptoms of this disease. This page will address the aspect of hip pain and associated mobility deficits.

Outcome Measures

Clinicians should use validated outcome measures that include domains of hip pain, body function impairment, activity limitation, and participation restriction to assess outcomes of treatment of hip osteoarthritis.

Measures to assess hip pain may include the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale, Brief Pain Inventory (BPI), pressure pain threshold (PPT), and pain visual analog scale (VAS). Activity limitation and participation restriction outcome measures may include the WOMAC physical function subscale, the Hip disability and Osteoarthritis Outcome Score (HOOS), Lower Extremity Functional Scale (LEFS), and Harris Hip Score (HHS). (Grade: A)

Pathoanatomical Features

Clinicians should assess for impairments in mobility of the hip joint and strength of the surrounding muscles, especially the hip abductor muscles, when a patient present with hip pain. (Grade: B)

Activity Limitation and Participation Restriction Measures

To assess activity limitation, participation restrictions, and changes in the patient’s level of function over the episode of care, clinicians should utilize reliable and valid physical performance measures, such as the 6-minute walk test, 30-second chair stand, stair measure, timed up-and-go test, self-paced walk, timed single-leg stance, 4-square step test, and step test. (Grade: A)

Clinicians should measure balance performance and activities that predict the risk of falls in adults with hip osteoarthritis, especially those with decreased physical function or a high risk of falls because of past history. Recommended balance tests for patients with osteoarthritis include the Berg Balance Scale, 4-square step test, and timed single-leg stance test. (Grade: A)

Clinicians should use published recommendations from the Academy of Geriatric Physical Therapy of the American Physical Therapy Association6 to guide fall risk management in patients with hip osteoarthritis to assess and manage fall risk.(Grade: F)

Physical Impairment

When examining a patient with hip pain/hip osteoarthritis over an episode of care, clinicians should document the flexion, abduction, and external rotation (FABER or Patrick’s) test and passive hip range of motion and hip muscle strength, including internal rotation, external rotation, flexion, extension, abduction, and adduction. (Grade: A)

Management / Interventions

Guidelines For Hip Pain Related To Hip Osteoarthritis

Table 1

Patient Education

Clinicians should provide patient education combined with exercise and/or manual therapy. Education should include teaching activity modification, exercise, supporting weight reduction when overweight, and methods of unloading the arthritic joints. (Grade: B)

Manual Therapy

Clinicians should use manual therapy for patients with mild to moderate hip osteoarthritis and impairment of joint mobility, flexibility, and/or pain. Manual therapy may include thrust, nonthrust, and soft tissue mobilization. Doses and duration may range from 1 to 3 times per week over 6 to 12 weeks in patients with mild to moderate hip osteoarthritis. As hip motion improves, clinicians should add exercises including stretching and strengthening to augment and sustain gains in the patient’s range of motion, flexibility, and strength. (Grade: A)

Flexibility, Strengthening, and Endurance Exercise

Clinicians should use individualized flexibility, strengthening, and endurance exercises to address impairments in hip range of motion, specific muscle weaknesses, and limited thigh (hip) muscle flexibility. For group-based exercise programs, effort should be made to tailor exercises to address patients’ most relevant physical impairments. Dosage and duration of treatment for effect should range from 1 to 5 times per week over 6 to 12 weeks in patients with mild to moderate hip osteoarthritis. (Grade: B)

Functional, Gait, and Balance Training

Clinicians should provide impairment-based functional, gait, and balance training, including the proper use of assistive devices (canes, crutches, walkers), to patients with hip osteoarthritis and activity limitations, balance impairment, and/or gait limitations when associated problems are observed and documented during the history or physical assessment of the patient. (Grade: C)

Clinicians should individualize prescription of therapeutic activities based on the patient’s values, daily life participation, and functional activity needs. (Grade: C)

Modalities

Clinicians may use ultrasound (1 MHz; 1 W/cm2 for 5 minutes each to the anterior, lateral, and posterior hip for a total of 10 treatments over a 2-week period) in addition to exercise and hot packs in the short-term management of pain and activity limitation in individuals with hip osteoarthritis. (Grade: B)

Bracing

Clinicians should not use bracing as a first line of treatment. A brace may be used after exercise or manual therapies are unsuccessful in improving participation in activities that require turning/pivoting for patients with mild to moderate hip osteoarthritis, especially in those with bilateral hip osteoarthritis.(Grade: F)

Weight Loss

In addition to providing exercise intervention, clinicians should collaborate with physicians, nutritionists, or dietitians to support weight reduction in individuals with hip osteoarthritis who are overweight or obese. (Grade: C)

Differential Diagnosis

Clinicians should revise the diagnosis and change their plan of care, or refer the patient to the appropriate clinician, when the patient’s history, reported activity limitations, or impairments of body function and structure are not consistent with those presented in the diagnosis/classification section of this guideline, or when the patient’s symptoms are not diminishing with interventions aimed at normalization of the patient’s impairments of body function. (Grade: F)

Resources

• Hip pain and mobility deficits—hip osteoarthritis: revision 2017: clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 47(6), A1-A37. : https://www.jospt.org/doi/10.2519/jospt.2017.0301

• Hip Pain and Mobility Guidelines (Revision 2017): https://www.jospt.org/doi/pdf/10.2519/jospt.2017.0301
• Guideline for the Management of Knee and Hip Osteoarthritis, 2nd Ed.: http://www.acsep.org.au/content/Document/guideline-for-the-management-of-knee-and-hip-oa-2nd-edition.pdf

References