Common Hip Pathologies- Functional Impairments and Management

Original Editor - Ewa Jaraczewska based on course by Rina Pandya
Top Contributors - Ewa Jaraczewska and Jess Bell


Introduction[edit | edit source]

The human body can adjust its centre of mass during every activity due to the opposing forces of the agonistic and antagonistic muscles. It helps provide functional joint stabilisation through dynamic stability,[1] and enables individuals to maintain balance and perform energy-efficient movements.[2] The timing and activation of dynamic stabilisers are the most important factors in achieving functional stability.[1]

When the body becomes off-balance, the muscles respond by counteracting changes in the centre of gravity. However, if imbalance persists, the completion of each movement requires more energy, leading to fatigue, pain and weakness.[2] The term "global effects" relates to the entire motor system compensating for a localised lack of stabilisation by altering movement patterns.[1] Physiotherapists should be able to identify which hip muscles are affected and develop effective exercise programmes to address these issues.[3]

The hip muscles play an important role during gait and functional tasks performed in standing positions. Imbalance, weakness or atrophy of specific hip muscles can change hip joint function during these activities and lead to the development of global effects of joint pathology. A study found that proximal hip weakness has caused anterior knee pain,[4] and was associated with functional ankle instability.[5] In addition, muscles with atrophy provide reduced proprioceptive feedback resulting in chronic pain and impaired postural stability, and the development of compensatory movements.[6]

The role of clinicians treating patients with hip pathology is to prescribe exercises targeting these dysfunctional muscles.[3]

"I simply try to go with the most basic, what I tell my patients is that we got to tighten up what's loose, loosen up what's tight and strengthen what's weak because we don't want the other muscles to work overtime". Rina Pandya[7]

Alignment and malalignment

Alignment[edit | edit source]

Postural alignment refers to a relative position of the head, shoulders, spine, hips, knees and ankles to each other.[8]

For an individual to maintain a standing position, every component of their postural alignment must be in perfect balance requiring the least amount of activities from the muscles. This person will be able to stand still and walk because of the lumbar lordosis, alignment of the upper spine, cervical spine lordosis, kyphotic thoracic spine and the appropriate alignment of the pelvis connecting to the lower extremities. When this alignment fails, malalignment can lead to significant deficiencies in balance and gait.[9] Altered postural alignment may be caused by muscle tightness or muscle weakness, eg., changes in length-tension in the hip flexors and hamstrings will affect pelvis position. According to Janda, "muscle imbalance is an impaired relationship between muscles prone to tightness or shortness and muscles prone to inhibition".[1]

Planes of movement

Planes of Movement[edit | edit source]

Movements in the hip joint occur in three planes of movement: flexion/extension in the sagittal plane, abduction/adduction in the frontal plane, and external/internal rotation in the transverse (horizontal) plane.

Sagittal[edit | edit source]

  • Hip movement in extension and flexion can be evaluated using the Modified Thomas Test (MTT) and the Straight-Leg-Raise (SLR).[10]
  • The Straight-Leg-Raise test allows the clinician to assess the flexibility of the hamstrings.[10]
  • MTT is only a valid measure of hip flexion contracture when lumbopelvic movement is controlled during testing.[11]

Frontal[edit | edit source]

  • The functional role of the hip abductor muscles is to provide frontal plane stability of the hip during the single-limb support phase of walking.[12]
  • The posterior head of the adductor magnus assists the hamstring with hip extension when other adductor muscles assist with hip flexion.[12]

Transverse (Horizontal)[edit | edit source]

  • When the hip joint is in flexion, the following external rotators become internal hip rotators: piriformis, posterior fibres of the gluteus minimus, anterior fibres of the gluteus maximus.
  • The range of hip rotation during gait varies between 2.8° to 11.8° and tends to be largest during the loading phase and midstance. The smallest hip rotation range occurs toward the end of the stance phase of gait.[13]
  • Hip internal rotation is needed to extend the hip toward the end of the gait cycle.[14]

Muscle Imbalance and Postural/Gait Deviations[edit | edit source]

An efficient gait pattern depends on the timing of muscle recruitment and balance.[15] The clinical presentation of the patient can help identify which muscles group are weak, tight or overstretched.[7] However, an in-depth assessment of range of motion, strength, muscle length and coordination is required to determine specific hip joint limitations.[16]

Sagittal[edit | edit source]

  • Excessive hip flexion can be caused by hip flexion contracture, iliotibial band contracture, hip flexor spasticity, compensation for knee flexion and ankle dorsiflexion, pain in the hip, or compensation for excessive plantarflexion in the mid-swing gait cycle.[7] Patients will demonstrate a compensatory bending to the side of excessive flexion to balance the centre of gravity of the body ("lurching gait"). During the stance phase of gait, the patient will tilt their trunk forward or compensate by excessive lordosis of the spine and an anterior pelvic tilt.[7]
  • Limited hip flexion or hip extension range of motion produces an excessive lumbar lordosis, and an abnormal length-tension relationship between the lumbar erector spinae and abdominal muscles. This leads to a "stretch-weakness" of the lower abdominals.[16] If shortened hip flexors are suspected, clinicians should not design stretching exercises for hip flexors or strengthening exercises for abdominal muscles based on observation of postural malalignments only. According to Heino et al.,[16] there is no correlation between hip extension range of motion, standing pelvic tilt, standing lumbar lordosis, and the double leg lowering abdominal muscle performance test. Instead, the assessment of joint mobility, muscle length, strength, and coordination are required to prescribe the most appropriate exercise programme.[16]
  • Reduction in hip flexion in the swing phase and hip extension during the stance phase can be observed in the arthritic hip, which causes an exaggeration of movement in the opposite limb (hip hiking on the unaffected side or "tiptoeing" on the affected side).[17]
  • Weak hip extensors can cause an increased femur lateral rotation during the push-off phase of the gait cycle. The person tends to take a smaller step to lessen the hip flexion required for initial contact. This reduces the force of contraction required from the extensors. Gait will be slower to allow time for limb stabilisation and a compensatory excessive posterior trunk positioning will help to maintain the alignment of the pelvis in relation to the trunk.[7] Patients may present with a lurch gait pattern due to gluteus maximus weakness.[15]
  • Hip extensors imbalance or stiffness results in increased lumbar extension and the patient exhibits anterior pelvic tilt.[15] A backward walking test can help to differentiate between gluteus maximus inhibition or weakness.[15] Increased lumbar lordosis or anterior pelvic tilt indicates a lack of hip extension due to muscle weakness.[15]
  • Weak hip flexors can result in a smaller step length. Gait will likely be slower and may result in decreased floor clearance of the toes,[7] and lead to toes dragging during midswing. In addition, the trunk shifts to the swing side, the pelvis lifts on the weight-bearing side, and leg circumduction occurs during the swing phase.[18]
  • Antalgic gait is characterised by the reduction of the gait stance and swing phases on the affected side. The trunk is propelled quickly forwards with the opposite shoulder lifted in an attempt to even the weight distribution over the limb and reduce weight-bearing on the painful side.[7]

Frontal[edit | edit source]

  • Hip abductor weakness will cause the hip to drop towards the side of the leg swinging forward or excessive pelvic rotation.[15] This is also known as Trendelenburg gait.[7]
  • Hip adductor contracture leads to a scissors gait,[7] which is characterised by extreme adduction of the hips with the knees and thighs hitting, or crossing, in a scissor-like movement. The antagonistic muscles (abductors) become weak.
  • Hip adductors weakness can be observed by femur abduction at heel strike, and an increased femur external rotation during midstance.[18]

Transverse (Horizontal)[edit | edit source]

  • Stiff or painful hips can present with limited hip joint rotation. In such cases, gait becomes asymmetrical, the base is widened during the swing phase, and there is a reduction of the stance phase on the involved side. To reduce tension on the joint, the hip is kept in flexion, abduction, and lateral rotation. There is a compensatory knee and ankle flexion.
  • Hip external rotation stiffness leads to a higher hip internal rotation during gait.[19]
  • Increased hip internal rotation and adduction overload the hip and knee joints and create a dynamic knee valgus.[19]
  • Limited internal rotation reduces the forward movement of the pelvis over the stance leg, which shortens the stride. The following are the most common compensations: feet overpronation, knee valgus, reduced step length, external rotation of the foot toward the terminal stance phase, and increased lumbar and knee extension.[14] With limited internal rotation, the compensatory excessive lumbar extension and knee hyperextension can lead to decreased hip extension.

Functional Gait Tests[edit | edit source]

Several mobility assessment tools can be identified targeting evaluation of gait, balance and transfers. Impairment in ambulation can have physical, cognitive, and social repercussions.[20] Physiotherapists should select the most appropriate assessment tool, which allows them to develop a plan of care and monitor patients' progress.[21]

The following are examples of functional gait tests.[7]

10 Meter Walk Test (10MWT)[edit | edit source]

The 10-meter walk test is commonly used to assess walking speed, health status, and functional ability in many conditions, including healthy adults, children with neuromuscular conditions, geriatric, hip fracture, traumatic brain injury, Parkinson's,[22] and others.[7] Various methods of test administering are described in clinical and research settings, including standing start, walking start, self-selected pace, and fast pace.[22]

[23]

6 Minute Walk Test (6MWT)[edit | edit source]

The Six-Minute Walk Test (6MWT) is a modified test to assess physical performance and mobility in a geriatric population.[20] This test was initially presented as an endurance test, but the research shows that it also offers information about the person's functional ability to ambulate.[24] This test is used to assess cardiovascular and pulmonary systems, peripheral circulation and the muscles' response to exercise.[25]

[26]

2 Minute Walk Test[edit | edit source]

The Two-Minute Walk Test is used to assess the overall endurance of patients with respiratory diseases, multiple sclerosis, lower extremity amputations, cystic fibrosis, TBIs, and other neurological conditions.[7] Patients with reduced endurance would benefit from a two-minute walk test.[7]

[27]

Dynamic Gait Index (DGI)[edit | edit source]

The Dynamic Gait Index helps to assess functional stability during gait activities. It is used in the elderly population to determine their risk of falling.[7] The higher the score the better functional mobility and balance stability. The short version of 4 items shows similar results as the 8-item DGI.[20]

[28]

Tinetti[edit | edit source]

The Tinetti Performance-Oriented Mobility Assessment (Tinetti-POMA) is also known as Tinetti Mobility Test (TMT). It is a clinical test for the assessment of balance and gait in the elderly population, as a measurement of mobility impairment and the effects of therapeutic interventions.[20]

[29]

TUG[edit | edit source]

Timed Up and Go (TUG) is a measure of balance and walking ability in geriatric populations. It consists of daily tasks including standing, walking and turning, so it is frequently used in clinical assessment.[20] It has been found to correlate well with Berg Balance Score, gait speed and Barthel Index.[20]

[30]

Evidence-Based Physiotherapy Protocols[edit | edit source]

  1. An evidence-based review of hip-focused neuromuscular exercise interventions to address dynamic lower extremity valgus.[31] Results:
    1. Knee abduction moment directly contributes to dynamic lower extremity valgus.
    2. Valgus of the knee alone can be a high predictor for ACL injuries.
    3. Hip external rotation moment predicts the ACL risk injury in young athletes who return after reconstructive surgery and rehabilitation.
    4. High knee abduction moment was predictive for both patellofemoral pain and ACL in the young females again.
    5. Post-ACL surgery, it is important to address hip stability.
  2. Are weight-bearing exercises after hip fracture surgery better than non–weight-bearing exercises or no exercise?[32]
    1. Type of exercise: Weight-bearing stepping exercises and non-weight-bearing exercises including abduction, flexion, and extension in supine.[7]
    2. Outcome measures: physical performance and mobility examination.[7]
    3. No difference existed in strength, gait, or function at the end of two weeks, between weight-bearing exercises and non-weight-bearing exercises.[7]
    4. After four months, weight-bearing exercises at home showed improvement in balance tests and the ability to walk more independently than the non-weight-bearing exercise group, but no significant decrease in strength or function was noted.[7]
  3. Progressive rehabilitation after total hip arthroplasty: a pilot and feasibility study.[33]
    1. Experimental group: a few supervised sessions between week zero and week 12 after THA followed by supervised progressive high-level activity retraining in the phases between week 12 and 16.[7]
    2. The training in the experimental group was tailored to the individual patient goals and their recreation and everyday life, and it was a structured approach for each patient.[7]
    3. Control group: set of exercises provided by the surgeon.[7]
    4. Scores were calculated for the following: pain, Timed Up and Go, the Stair Climb Test, the Six-Minute Walk Test, a 30-second chair rise test, Hip Outcome Scale, Hip Dysfunction and Osteoarthritis Outcome Score for joint replacement (HOOS), the ground reaction force during stance, hip abduction moment, sit to stand ground reaction force, and the symmetry between the limbs during stance and sit to stand were compared between the groups.[7]
    5. The experimental group showed significant positive results on their biomechanics and functional outcome when compared to the control group.[7]

Resources[edit | edit source]

References[edit | edit source]

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  2. 2.0 2.1 Pizones J, García-Rey E. Pelvic motion the key to understanding spine–hip interaction. EFORT Open Reviews. 2020 Sep 7;5(9):522-33.
  3. 3.0 3.1 Mendis MD, Wilson SJ, Hayes DA, Hides JA. Hip muscle atrophy in patients with acetabular labral joint pathology. Clinical Anatomy. 2020 May;33(4):538-44.
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  6. McPartland JM, Brodeur RR, Hallgren RC. Chronic neck pain, standing balance, and suboccipital muscle atrophy--a pilot study. J Manipulative Physiol Ther. 1997 Jan;20(1):24-9.
  7. 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12 7.13 7.14 7.15 7.16 7.17 7.18 7.19 7.20 7.21 7.22 Pandya R. Rehabilitation Protocols and Treatment Strategies for the Hip - Part 2. Physiopedia Course. 2022
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  10. 10.0 10.1 Rose-Dulcina K, Vassant C, Lauper N, Dominguez DE, Armand S. The SWING test: A more reliable test than passive clinical tests for assessing sagittal plane hip mobility.Gait & Posture 2022; 92: 77-82.
  11. Vigotsky AD, Lehman GJ, Beardsley C, Contreras B, Chung B, Feser EH. The modified Thomas test is not a valid measure of hip extension unless pelvic tilt is controlled. PeerJ. 2016 Aug 11;4:e2325.
  12. 12.0 12.1 Neumann DA. Kinesiology of the hip: a focus on muscular actions. Journal of Orthopaedic & Sports Physical Therapy. 2010 Feb;40(2):82-94.
  13. Uemura K, Atkins PR, Fiorentino NM, Anderson AE. Hip rotation during standing and dynamic activities and the compensatory effect of femoral anteversion: An in-vivo analysis of asymptomatic young adults using three-dimensional computed tomography models and dual fluoroscopy. Gait Posture. 2018 Mar;61:276-281. doi: 10.1016/j.gaitpost.2018.01.016. Epub 2018 Jan 31. PMID: 29413797; PMCID: PMC6599491.
  14. 14.0 14.1 Dawson H. The importance of hip internal rotation. Available from:https://exclusive.multibriefs.com/content/the-importance-of-hip-internal-rotation/medical-allied-healthcare29.10.2014[last accessed 18.04.2022]
  15. 15.0 15.1 15.2 15.3 15.4 15.5 Page P, Frank CC, Lardner R. Chapter 5. Posture, balance, and gait analysis. In: Assessment and treatment of muscle imbalance. The Janda approach. Page P, Frank CC, Lardner R, editors. Human Kinetics: Champain,IL, USA. 2010.
  16. 16.0 16.1 16.2 16.3 Heino JG, Godges JJ, Carter CL. Relationship between hip extension range of motion and postural alignment. Journal of Orthopaedic & Sports Physical Therapy. 1990 Dec;12(6):243-7.
  17. Malanga G, DeLisa JA. Clinical Observation. Available from: https://www.rehab.research.va.gov/mono/gait/malanga.pdf. [last access 18.04.2022]
  18. 18.0 18.1 Schafer RC.Chapter 4: Body Alignment, Posture, and Gait. In: Clinical Biomechanics: Musculoskeletal Actions and Reactions.Second Edition,1987. Available from: https://www.chiro.org/ACAPress/Body_Alignment.html. [last accessed 16.04.2022].
  19. 19.0 19.1 Alves Diniz KM, Alves Resende R, de Oliveira Mascarenhas R, de Jesus Silva H,Trede Filho RG, De Michelis Mendonça L. Hip passive stiffness is associated with hip kinematics during a single-leg squat. Journal of Bodywork and Movement Therapies, 2021;28: 68-74.
  20. 20.0 20.1 20.2 20.3 20.4 20.5 Soubra R, Chkeir A, Novella JL. A Systematic Review of Thirty-One Assessment Tests to Evaluate Mobility in Older Adults. Biomed Res Int. 2019 Jun 20;2019:1354362.
  21. VanSwearingen JM, Brach JS. Making geriatric assessment work: selecting useful measures. Phys Ther. 2001 Jun;81(6):1233-52.
  22. 22.0 22.1 Lindholm B, Nilsson MH, Hansson O, Hagell P. The clinical significance of 10-m walk test standardizations in Parkinson's disease. J Neurol. 2018 Aug;265(8):1829-1835. doi: 10.1007/s00415-018-8921-9. Epub 2018 Jun 6. PMID: 29876762; PMCID: PMC6060742.
  23. Mission Gait. 10 Meter Walk Test - Setup and Instruction. 2017. Available from: https://www.youtube.com/watch?v=jKZcQM5PGq8 [last accessed 19/04/2022]
  24. Harada ND, Chiu V, Stewart AL. Mobility-related function in older adults: assessment with a 6-minute walk test. Arch Phys Med Rehabil. 1999 Jul;80(7):837-41.
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  28. Talia Tortomasi. Dynamic Gait Index (DGI) Demonstration - UNLV PT '17. 2016. Available from: https://www.youtube.com/watch?v=OPM9-aG1UMo[last accessed 19/04/2022]
  29. Mizah Jumali. Tinetti Balance Assessment Tool. 2018. Available https://www.youtube.com/watch?v=s5LB61DmdX8[last accessed 19/04/2022]
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  31. Ford KR, Nguyen AD, Dischiavi SL, Hegedus EJ, Zuk EF, Taylor JB. An evidence-based review of hip-focused neuromuscular exercise interventions to address dynamic lower extremity valgus. Open Access J Sports Med. 2015 Aug 25;6:291-303.
  32. McCarthy T, Oberstar J. Are weight bearing exercises after hip surgery better than nonweight bearing exercise or no exercise? Evidence-Based Practice. 2018 Sep;21(8):17-18.
  33. Madara KC, Marmon A, Aljehani M, Hunter-Giordano A, Zeni J Jr, Raisis L. PROGRESSIVE REHABILITATION AFTER TOTAL HIP ARTHROPLASTY: A PILOT AND FEASIBILITY STUDY. Int J Sports Phys Ther. 2019 Jul;14(4):564-581.