HIP PAIN CAN MAKE IT DIFFICULT TO FUNCTION
. It hurts to walk and to sit. The conservative care offered by doctors of chiropractic (DCs) is a great first option for patients to consider when suffering from hip problems. Many benefits flow to the patient who seeks chiropractic first.
Larry Wyatt, DC, DACBR, FICC, professor/ senior faculty, division of clinical sciences at Texas Chiropractic College, notes that many causes of hip pain are biomechanical. “Given the manual medicine approach that chiropractors take, manual therapies such as mobilization, manipulation and therapeutic exercise, along with ergonomic training, can be quite helpful in managing these patients,” he says.
Leo Bronston, DC, MAppSc, vice president of ACA’s Council of Delegates and owner of six chiropractic clinics in Wisconsin, points out that because technology is changing so fast, leading to many advancements in hip surgery, the longer a patient can put off an inevitable hip replacement, the better the outcome.
Dr. Bronston sees patients generally presenting with pain that occurs during an activity or functional event. He explains that when the DC identifies the hip pathology and related structures involved, he or she can create a treatment plan, such as loosening up the soft tissues, creating traction with the hip to gain more space and breaking up adhesions or restrictions. “It prolongs the use of the body so the patient can plan out when to have a hip replacement,” he says.
Another benefit is to have immediate relief without resorting to pharmacology. That should be a last resort, because it’s not hip specific and can affect other functions. “Chiropractic can prolong a patient’s expectancy to be pain-free and the ability to function without resorting to drugs or surgery for a longer period,” Dr. Bronston says.
The Hip or the Spine?
Both DCs agree that from their perspective, the general treatment options for the spine and hip are similar, given that you will be managing biomechanical problems in the hip. But Dr. Bronston points out that the hip takes him longer to care for in a clinical session than an uncomplicated lowerback problem.
He explains why. “A lot of uncomplicated lower back and spinal conditions are requiring the DC to address the specific area of complaint, so for example you take care of just the spinal segment and maybe look at some pelvic alignment as well. But when you examine the hip, you have a complex muscular system that is a pivot point between your spine and your foot.”
Dr. Wyatt also points out that management of a hip condition does afford the clinician the use of appliances such as walkers and canes, which are typically not useful for spine disease. His experience is that long axis traction maneuvers and circumduction exercises, both passive and active, are helpful with hip pathology but not particularly helpful for spine disease.
Testing and Diagnosis
The primary way a DC knows the patient is dealing with a hip problem is via testing. Hip issues can make for a difficult differential diagnosis, so the DC has to use several tools to determine the source of the pain.
“There are some well-designed physical exam procedures and orthopedic tests that can diagnose hip disease with a high degree of certainty,” says Dr. Wyatt. Dr. Bronston uses orthopedic tests, including the range-of-motion test.
“The challenge is that these tests and procedures are not as accurate at defining the exact nature of the pathology,” says Dr. Wyatt.
Dr. Bronston says that when the hip has mechanical pathology, it may throw off the patient’s gait, which can affect the lower back as well as the pelvis and the knee. Dr. Wyatt notes that the distinctive gait pattern is called a lurch and is an attempt by the patient to shift his or her weight to avoid causing hip pain.
The location of the pain is also helpful. “Patients with hip joint pathology often point to the area of maximum pain intensity in the groin approximately halfway between the ASIS and the symphysis pubis,” says Dr. Wyatt. “While other areas of discomfort might be present, this anterior region tends to be most painful in patients with true hip joint pathology.”
“A clinical history of difficulty bringing the foot up to put on socks or shoes, activities involve twisting the hip, difficulty with stairs and sitting and rising from a seated position all suggest hip pathology,” Dr. Wyatt adds.
Sometimes, patients can have lumbar spine and hip pathology at the same time. This adds to the confusion, but testing and imaging are usually successful at telling between them.
Dr. Bronston believes the most important takeaway is when examining even the lower back, the DC needs to look at the hip because often, especially in an aging population, the hip has degenerative changes or may have labral tears that can be identified by an orthopedic examination and/ or imaging depending on whether it’s soft tissue or bony degenerative changes. “It’s a multitude of tests that have to be utilized and then try to narrow down to where the source of the pain and dysfunction is emanating from. But it is not always decisively related to one area,” he says.
Common Hip Injuries
“The most likely hip pathology seen in adults by DCs is degenerative joint disease,” says Dr. Wyatt. It produces hip stiffness and substantial alterations in a patient’s normal activities of daily living.
While he does treat a lot of degenerative hips, Dr. Bronston is presented with more cases of hip impingement syndromes and is now seeing surgical procedures used for its treatment, which was not the case five or ten years ago. He usually relieves impingement with chiropractic techniques, such as extremity mobilization to the hip and other soft-tissue and ancillary modalities. “I question, from a clinical perspective, whether more people are getting impingement surgically repaired when they should try something more conservative,” he says. “I think anyone needs to look at the evidence and the long-term effect of having that surgery as opposed to trying conservative intervention.”
Dr. Wyatt says, “Other common pathologies of the hip include muscle strains, capsular sprains and bursitis. In addition, hypertonicity/spasm of the tensor fascia lata muscle may lead to biomechanical alterations in the hip and may contribute to reduced performance and pain in athletes.” One other problem to be considered in patients with hip/anterior thigh pain is meralgia paresthetica (MP). Dr. Wyatt explains that in MP, “there is entrapment of the lateral femoral cutaneous nerve, often in obese patients. Manual therapies, along with weight loss, can be helpful in some of these cases.”
Dr. Bronston recently took part in a multidisciplinary intervention, when a patient came in with what appeared to be sciatica disguised as leg, back, lower-back and buttock pain. What complicated this patient’s condition was stage 2 hypertension producing swelling in his lower limbs. Dr. Bronston treated his hip with mechanical intervention traction and mobilization, while addressing some of the gluteus musculature to free up that sciatic nerve, and the patient experienced improvement immediately. But Dr. Bronston knew he needed to get his blood pressure under control and made a referral so the patient could go on a diuretic. The improvement was even more significant, as lower extremity edema was relieved.
“The lesson is that there are so many people who are not getting the right care,” says Dr. Bronston. “One of the biggest issues I see with accountable care is many people don’t know about preventive care or what is being paid – the deductibles are too high, and they are not seeking providers.” He believes this is an opportunity for DCs, who are known as being cost-effective and can perform preventive screening of patients.
Hip Considerations in Young and Old
In pediatric patients, be on the lookout for Legg-Calve-Perthes (LCP) disease, says Dr. Wyatt. This is a form of avascular necrosis of the femoral capital epiphysis that can be asymptomatic and in some cases, refer pain or only cause knee pain. Residual deformities of the femoral head can lead to precocious degenerative joint disease where a patient may seek care during adulthood. The adult analogue of LCP is spontaneous osteonecrosis of the hip, seen in alcoholics, patients with hip injuries, long-term corticosteroid use and other diseases, such as sickle cell and systemic lupus erythematosus.
Slipped femoral capital epiphysis, a Salter-Harris Type I fracture, should also be considered in pediatric patients with hip pain, especially those who are active.
In the geriatric population, be cognizant of two conditions in particular: hip fractures and malignancy. Hip fractures are a common cause of morbidity and mortality, and a small percentage of those fractures can be occult. In some cases, normal activities of daily living may result in an insufficiency fracture of the hip that is difficult to visualize on conventional radiography. If the index of suspicion for a hip fracture is high, but conventional AP and frog leg views of the hip are normal, advanced imaging of the hip with MRI, CT scanning or radionuclide bone scanning can confirm such suspicions. Of the three, MRI is considered the gold standard.
Malignancy, especially metastases to the hip, is a potential diagnosis in the elderly with an insidious onset of pain. Conventional radiography will often identify these lesions. But if plain films are normal, the same three imaging modalities may be used. Radionuclide bone scanning has the advantage, in a search for metastases, to identify lesions throughout the skeleton at a relatively low cost.
Hip Osteoarthritis and Manual Therapy
The American College of Rheumatology (ACR) has accepted evidence from many randomized placebo controlled trials that there is no difference between real arthroscopy, with actual surgical debridement or lavage, and sham arthroscopy, with only a real surgical cut but no debridement. The evidence from these trials is so strong that ACR's 2012 guidelines now strongly recommend against common or routine arthroscopic surgery for hip or knee osteoarthritis.
For the first time in history, the ACR has recommended that manual therapy, if added to exercise or rehabilitation, may further benefit hip or knee osteoarthritis. The foremost recommended manipulation is HVLA Grade V thrust manipulation to the hip joint, and lesser grades in some cases. For more on the subject, go to the ACA Rehab Council website at www.ccptr.org/news/new-ebook-out-by-james-brantingham-dc-phd/