Hip Pain and Mobility Deficits

Original Editors - Tyler Shultz

Top Contributors - Tyler Shultz, Sehriban Ozmen, Amanda Ager, Admin, Evan Thomas, Kim Jackson, Lauren Lopez, WikiSysop and Vidya Acharya

Background

Hip pain can arise for a variety of reasons, most commonly caused by hip osteoarthritis (OA). OA is of a chronic nature, most commonly characterized as a form of chronic arthritis. This can present with joint pain, swelling, stiffness, and reduced mobility.

Risk factors 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.

Clinical Practice Guidelines (updated 2017)

The following guidelines have been retrieved from Cibulka et al. (2017). (Table 1)

Table 1

The purpose of this clinical guideline is to describe the evidence based physical therapy practice including diagnosis, prognosis, intervention and assessment of outcome for musculoskeletal disorders related to hip osteoarthritis that are commonly managed with orthopaedic physical therapy techniques.

Diagnosis & Classification Recommendations

Diagnosis/Classification

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)

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)

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)

Examination Recommendations

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).

Anterior view of the right hip joint.

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)

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)

Intervention & Treatment Recommendations

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)

Other Resources:

• 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