Background & Etiology
The hip joint is one of the largest joints in the body. It is composed of one osseous (bony) joint. The hip is built for weight bearing and movement in several different planes. Most of the stability of the hip is derived from the joint design, joint capsule, ligaments, muscle and a cartilaginous tissue called the labrum.
Bone and Joint
The hip, like the shoulder, is a ball and socket joint. It is formed by the head of the femur (thigh bone), which sits in the acetabulum, a part of pelvis. The head of the femur is a large ball and the acetabulum is a shallow socket. This design of the joint allows for greater mobility.
The bony joint surfaces of the head of the femur and acetabulum are covered with articular cartilage. The articular cartilage has a smooth and shiny surface that allows the ends of the bones to slide freely over each other. This is what enables the joint to move smoothly.
Arthritis is the wearing, degeneration or loss of articular cartilage in a joint. The three most common types of joint arthritis are osteoarthritis, rheumatoid arthritis, and traumatic arthritis. The most common cause of hip pain is arthritis.
The most common form of hip arthritis is Osteoarthritis. Osteoarthritis is a gradual wearing down and degeneration of the joint surfaces or articular cartilage. Osteoarthritis is most common in people who are middle age or adults over the age of 50, and people who are overweight. Women are more likely to develop osteoarthritis, which can affect one hip or both. Hip osteoarthritis is the most common cause of disability.
Common causes of hip osteoarthritis include:
- Genetics and family history can predispose individuals to developing osteoarthritis and joint degeneration
- Traumatic injury or fracture of the hip can result in the development of osteoarthritis.
- Significant trauma that effects the circulation of the head of the femur. This condition is called aseptic necrosis and can result in the degeneration of the ball, or femoral head.
- Excessive use of steroids or steroid medication can result in degeneration of the joint and cartilage.
- Obesity that causes increased weight and pressure on the hip joints, when performing everyday activities. This puts added stress on the hips, which increases force on the joint cartilage.
- Diseases of the joint cartilage
Symptoms of Osteoarthritis
- Pain and achiness in the hip joint during activities. Hip pain may be reported on the outside of the hip, groin and even refer down the leg to the knee.
- Difficulty with walking and weight bearing on the involved leg.
- Loss of motion of the hip in several directions including abduction (moving out) flexion (moves toward chest) and internal rotation (turning the hip in). Stiffness that may improve with movement.
- Noticeable swelling around the joint.
- Weakness that makes it difficult to get out of chair, squat, kneel or climb stairs
- Cracking, grinding, crunching or joint noises called crepitus that occur when moving the hip. This may happen as the cartilage surfaces wear and there is bone-on-bone rubbing, or bony spurs.
Unlike other forms of arthritis, rheumatoid arthritis is a systemic autoimmune disease that is not caused by common wear and tear on the joint. This condition usually affects joints symmetrically (for example, both knees, both wrists, both shoulders). Rheumatoid arthritis causes degeneration of the articular or joint cartilage. It can also affect the tissue that surrounds and lubricates the joint (synovium). If the joint surfaces and cartilage are not lubricated they can start to rub, causing the wear that leads to arthritis pain.
Rheumatoid arthritis can affect other parts of the body including organs like the heart and lungs, and can even cause fatigue. The cause of Rheumatoid arthritis is not fully known. It is considered an autoimmune disease where the cells of the body attack themselves. Although it is a chronic condition, individuals can have periods with little to no symptoms mixed with acute or symptomatic periods. There can be a genetic component to this disease.
Symptoms of Rheumatoid Arthritis
- Pain, often severe, is present over the hip joint, groin, and can be referred down the leg to the knee, often affecting both the right and left joints.
- Swelling and inflammation of the joint.
- The joint will feel hot or warm to the touch.
- Stiffness and loss of motion of the hip when moving the hip in several different directions.
- Weakness, which may be manifested as difficulty walking, getting up from a sitting position, kneeling, squatting and climbing stairs.
- Fatigue or tiring easily when performing normal daily activities
Treatment of Hip Arthritis
Treatment of hip arthritis will depend on the severity of the condition. Some important guidelines should be followed at the onset:
Rheumatoid Osteoarthritis Considerations
The ideal treatment involves a combination of medication, rest, joint range of motion and strengthening exercises, joint protection strategies and patient education. Restoring range of motion and strength is paramount to maintaining function. Treatment is customized depending on the individual’s age, level of function, acute vs. chronic flare up, pain level and general health.
- Rest: avoid the activities that produce the pain. Avoid jumping, running, going up and down stairs, kneeling, squatting and walking for extended periods of time.
- Ice or moist heat: apply ice to the joint or area experiencing pain or inflammation. It is one of the fastest ways to reduce swelling, pain and inflammation. Individuals with Rheumatoid arthritis may not tolerate ice well. The application of moist heat may be helpful with stiff joints. The application of ice or heat should be done at intervals for about twenty minutes at a time. Do not apply directly to the skin.
- Compression: when using ice, apply light compression. This is especially helpful if swelling is present.
- Elevation: elevate the area to help reduce swelling.
- Movement: keep your joints moving whenever possible. When pain occurs the tendency is not to move, but this will only result in further loss of motion and lead to increased pain and loss of function.
Mild: In mild cases rest, ice and medication may be all that is needed to reduce the pain. Once the pain is reduced physical therapy is recommended to develop a series of stretching and strengthening exercises to prevent loss of motion, weakness and function. Individuals are advised to avoid becoming sedentary; however return to full activity should be gradual to prevent a flare up of symptoms.
Moderate to Severe: If the problem persists, consulting your health care provider should be the next step. Your physician and/or physical therapist will perform a thorough evaluation to determine the severity of the condition and the best course of treatment.
Physical Therapy Interventions
Physical Therapists are professionals, educated and trained to administer interventions. As defined by The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and the patient or client’s goals.
Your physical therapist will perform a thorough evaluation to assess and determine the following:
- Joint: a series of measurements will be performed to determine which joint is involved and the extent to which the inflammation is acute
- Strength: resisted testing is performed to determine if there is associated weakness or strength imbalances
- Flexibility: range of motion measurements will be taken to determine if there is reduced joint movement
- Technique and ADL: the therapist will review what activities you have difficulty with and will help you make modifications in technique to reduce stress on the involved joint.
- Gait, Balance and Alignment: the therapist will assess your gait and balance on even and uneven surfaces. An assistive device such as a cane or walker may be indicated to improve safety, gait and reduce stress on the effected joint.
Physical therapy for hip arthritis must remain conservative at the onset to avoid aggravating the condition. Emphasis will be placed on rest, reducing the inflammation, protecting the joint and increasing the blood circulation for healing. Once the initial inflammation has reduced, a program of stretching and strengthening will be initiated to restore flexibility and improve strength to reduce stress on the hip joint. An assistive device for ambulation, or moving around, may be necessary to decrease weight bearing on the hip and normalize the gait.
Physical Therapy Interventions
Common Physical Therapy interventions in the treatment of Hip Arthritis include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to improve alignment, mobility and range of motion of the hip. The use of mobilization techniques also helps to modulate pain.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen muscles of the hip and lower extremity to support, stabilize and decrease the stresses place on joint cartilage and the hip joint.
- Neuromuscular Reeducation (NMR) to restore stability, retrain the lower extremity and improve movement techniques and mechanics (for example, walking, bending, or stair climbing) of the involved lower extremity to reduce stress on the joint surfaces in daily activities. Gait and balance training may be indicated in those individuals who have problems with walking.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold, laser and others to decrease pain and inflammation of the involved joint.
Avoiding the activities that produce the pain or stress the involved joint is the first line of treatment.
- RICE: Rest, Ice, Compression, Elevation should be used to reduce the stress on the joint.
- NSAIDS (Non steroidal anti-inflammatory drugs) to reduce pain
- Use of an assistive device such as a cane or walker may reduce stress on the hip while reducing a limp or gait deviation.
- Injection of steroids may be indicated to reduce inflammation of the involved joint.
- In severe recurrent conditions surgery may be indicated. In cases of severe arthritis or joint degeneration a hip joint resurfacing or total hip replacement procedure may be recommended.
Medical Management of Rheumatoid Arthritis
Early aggressive medical care is recommended for individuals with Rheumatoid Arthritis. Interventions may include the following:
- The use of DMARD (disease modifying anti-rheumatic drugs).
- The use of NSAIDS (non-steroidal anti-inflammatory drugs)
- When indicated steroids in low doses will be prescribed to reduce joint inflammation.
- Physical and Occupational Therapy to develop a stretching and strengthening program.
- Bracing and splinting to protect and rest the involved joints
- Surgery may be indicated in severe cases. An arthroscopic procedure to remove an inflamed synovial lining is one surgical option. In the case of severe joint and cartilage degeneration a total hip replacement is the preferred procedure.
Outcomes and prognosis for individuals with hip arthritis will depend on the severity of the joint degeneration, motion loss, weakness and age of the individual.
Mild: Individuals with mild degeneration respond well to conservative treatment, which includes medication for pain and inflammation and a program of exercises for stretching and strengthening of the knee joint and surrounding muscles. Most patients show improvement in pain and function in 4-6 weeks.
Moderate: Individuals with moderate degenerative changes usually experience greater loss of motion, pain, weakness and loss of function. In some cases a joint resurfacing of the hip may be indicated. Recovery may take from 8-12 weeks following surgery with emphasis on reduction of swelling and restoration of range of motion, strength and function.
Severe: Individuals with severe joint degeneration have significant pain, stiffness, loss of motion and function. The cartilage on the joint surfaces has been eroded and X-rays reveal a loss of joint space and “bone on bone” contact. Joint replacement is the treatment of choice. At this point quality of life becomes a concern. Following a joint replacement the artificial hip will be different from the natural joint and there will be some limitations of motion and function. However, a patient’s quality of life is usually significantly improved following a total joint replacement. Recovery following hip replacement can take 3-4 months of intensive physical therapy and rehabilitation. Improvements and functional gains can continue to develop for up to a year following the procedure.
This surgical procedure is an alternative to total hip replacement. Younger individuals who are not overweight are good candidates for this procedure. It involves the placement of a cap over the head of the femur and the use of a metal cup in the acetabulum (socket) of the pelvis. There is less bone loss required in this procedure and the risk of dislocation is reduced. It is recommended for patients who do not have large bone loss, rheumatoid arthritis or osteoarthritis.
Total hip replacement may be indicated in severe cases of osteoarthritis, rheumatoid arthritis or traumatic arthritis secondary to a fracture. It may be indicated in the case of aseptic necrosis in which the circulation of the head of the femur is compromised resulting in degeneration of the ball of the hip. There are several different designs for hip replacements but all have two components: the ball made of highly polished strong metal or ceramic and the socket, a durable cup made of plastic, metal, or ceramic material. Cement may or may not be used to stabilize the prosthesis on the existing bone.
Once the pain and inflammation is reduced, and motion and strength are improved it is important that the patient returns to full activity gradually. Instruction in daily activities and a comprehensive home program are helpful for reducing a reoccurrence of flare-ups and slowing the degenerative process. As a preventive measure individuals should:
- Movement: keep moving and avoid a sedentary lifestyle. Joints are meant to move and depend on movement for lubrication. Sitting and remaining sedentary will reduce the joint’s available range of motion.
- Stretching: stretching regularly, in addition to before and after activity, will reduce the chances of developing joint stiffness and pain. Stretching will also improve and maintain the elasticity and flexibility of muscles and tendons of the joint. Hold stretches for 20 seconds and do not bounce. Remember, as joints age flexibility is lost. It is part of the aging process.
- Strength: performing a regular strength program will keep muscles strong enough to absorb the stresses placed on the joints. Weak muscles allow the stress and forces of every day activities to be transferred to the joint surfaces. Remember, as people get older weakness increases.
- Protection: Avoid activities that place increased stress on the hips. This includes running or high impact activities.