The hip joint is a fantastically congruent ball and socket synovial joint making it a particularly stable connection point between the leg and pelvis

Pathology affecting the hip joint can drastically alter function due to being such an important joint for the appropriate functioning of the entire lower limb. 

Age related changes due to historial load through work, leisure and sports activities can lead to hip osteoarthritis that will sometime require the need for a total hip replacement if the joint is damaged significantly.

Femoroacetabular impingement syndrome (FAI), labral or CAM lesions, groin pain and gluteal tendinopathy are all injuries that can be caused by lack of control of the twist and turning load required for many sports and activities of daily living.

Great strength and control of the low back, hips, pelvis and entire low limb can reduce the unnecessary load on the hip and therefore reduce risk of injury.

Femoroacetabular impingement syndrome (FAI)

Femoroacetabular impingement syndrome or FAI is a condition of abnormal movement within the hip joint causing symptoms. The ball (femoral head) and socket (acetabulum) rub abnormally, leading to symptoms, clinical signs and changes in morphology (the particular form, shape, or structure). To diagnose FAI, syndrome symptoms, clinical signs and imaging findings must all be present.

What causes FAI syndrome?

FAI syndrome occurs when an overgrowth of bone on the ball, socket, or both parts of the hip joint (known as cam or pincer morphology), prevents normal movement of the joint. It is likely that FAI syndrome is the result of a combination of an individual’s genetics and environment. Some experts believe that significant athletic activity before skeletal maturity increases the risk of FAI, but evidence is not definitive at this stage. Recent reviews have found FAI morphologic features are common in people who have no symptoms, particularly athletes.  


How do I know if I have FAI syndrome?

FAI often presents as hip and groin pain with restricted range of hip motion. Symptom onset can be acute, after an injury, or insidious (slow onset). Pain often comes on with prolonged sitting, walking, crossing the legs, or during and after sport or exercise. Pain is primarily felt deep in the groin at the front of the hip. More rarely, it can be on the side of the hip or the buttock. Symptoms, clinical findings and imaging findings must be present to diagnose FAI. Your GP or physiotherapist can diagnose FAI by asking about your symptoms, examining your hip movements and ordering imaging if appropriate. Antero-posterior X-rays can be undertaken to confirm the diagnosis. Where further assessment of hip structures is needed, cross-sectional imaging may be appropriate. 


How can physiotherapy help with FAI syndrome?

Physiotherapy for FAI aims to improve hip strength, neuromuscular control, range of motion, balance and patterns of movement. Your physiotherapist may use a variety of techniques to stretch any tight structures, including the joint capsule or muscles. Physiotherapy will improve soft tissue flexibility and length, strengthen the supporting hip muscles, progress hip muscle proprioception, joint position sense and functional control to dynamically control your hip. Treatment should also include education about the condition, activity and lifestyle modifications.

Surgery for FAI?

Open or arthroscopic (minimally invasive) surgery can be performed to improve the hip structure, and repair or remove damaged tissues. There is no current evidence to suggest that surgery will reduce the risk of later developing osteoarthritis, or ‘cure’ your hip problem. Physiotherapy post-surgery is important for assisting people in regaining range of movement, strength, mobility and returning to sport. The decision regarding surgery should be made after consultation with your physiotherapist and doctor.


How effective is physiotherapy for FAI syndrome?

There is currently no high-level evidence to support the choice of one treatment for helping the symptoms of FAI. However, people with FAI have been shown to have problems with hip function, including muscle weaknesses and loss of range of motion. Exercise prescribed by physiotherapists is effective at addressing these issues in many other conditions. A systematic review found very few studies examining physiotherapy for FAI. Studies are currently underway directly comparing physiotherapy to surgical intervention.


What can I do at home?

Taking note of, and limiting aggravating activities and positions is helpful for when you consult your physiotherapist. Avoid placing your hip into positions that cause pain—these are generally when the hip is bent up and twisted in or out, and can include sitting with legs crossed, pivoting and squatting in sports.

Use of painkillers and anti-inflammatories may temporarily help the pain and reduce the local anti-inflammatory reaction.


How long until I feel better?

Symptoms frequently improve for people with FAI when treated. Without any treatment, symptoms are likely to gradually worsen over time. The long-term outlook for people with FAI is currently not known, as well as whether treatment for FAI can prevent later development of hip osteoarthritis.


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Gluteal tendinopathy is a common cause of pain at the side of the hip. This condition is still often referred to as trochanteric bursitis, however researchers have now determined that the primary problem is a reduction in health and load tolerance of the gluteus medius (an important muscle in controlling the hips) and minimus tendons. Gluteal tendinopathy is more common in women than men. Research has shown that about 1 in 4 women over the age of 50 suffer from lateral hip pain.

What causes gluteal tendinopathy?

Researchers are still working on clearly determining the causes of tendinopathy. It is currently thought that the pain of gluteal tendinopathy often appears when the tendons become overloaded. This may be due to rapid increases in training or exercise load, a large force associated with a slip or fall or an increase in bodyweight. Sometimes there has been no particular incident but there may have been a gradual weakening of the tendons over time associated with lack of stimulus of the gluteals due to low activity levels, or certain postural and movement habits.

Those with gluteal tendinopathy have been shown to have weakness in the gluteal muscles that attach to the problem tendons. If the muscles and their tendons become weak enough, they will fail to cope with everyday loads and your nervous system may warn you about this in the form of pain.


How do I know if I have gluteal tendinopathy?

The pain associated with gluteal tendinopathy is usually centred over the greater trochanter, the large bone that you can feel at the side of the hip, but may extend down the outer thigh towards the knee. Pain may be felt when walking, particularly at speed, uphill or upstairs and when standing on one leg to dress. It is common to experience pain and a feeling of stiffness when rising from a chair after prolonged sitting. Night time is often worse, particularly when lying on your side.

Your physiotherapist will take note of your history and symptoms and perform a number of physical tests in order to diagnose gluteal tendinopathy and rule out other potential sources of pain. Radiological investigations such as an ultrasound scan or MRI may be used to confirm the diagnosis. Many people without pain have tendon changes on scans, therefore clinical testing is required to determine whether scan findings are relevant to your current condition. It is not necessary to have scans before presenting to your physiotherapist for assistance. Most people can be diagnosed with clinical tests.


How can physiotherapy help with gluteal tendinopathy?

Physiotherapy can help in multiple ways. Your physiotherapist can advise you about controlling aggravating tendon loads—everyday postures, movement habits and activities that might be provoking your pain. Your physiotherapist can help to address poor postural and movement habits, including gait retraining.

Research has found that exercise provides the best long-term outcomes for tendon pain. A specific exercise program that aims to improve your movement patterns, gradually strengthen the muscles involved and improve the health of your hip tendons is essential. Massage, self trigger point releases, acupuncture, dry needling and heat may assist with short term symptomatic pain relief. However, a specific exercise program and being taught how to control loads across your tendons are key strategies in managing this condition for the longer term.

Stretching of the gluteals or Iliotibial band (ITB), while a common strategy, will usually only aggravate the tendons. Corticosteroid injections have previously been recommended, but these have been found to have only short term benefits. Surgery is reserved for cases that have not responded to any conservative treatments.


How effective is physiotherapy for gluteal tendinopathy?

There is currently a lack of evidence available from clinical trials for any interventions specifically designed for people with gluteal tendinopathy. Given this limited information, physiotherapists use information from other tendinopathy research, which shows that addressing the underlying causes of the tendinopathy and known strength deficits is the best way to manage tendinopathy.


What can I do at home?

Avoid stretching and rubbing firmly over the bone and avoid activities that worsen your pain. It is important to remember that complete rest does not heal tendon problems and the more inactive you become, the weaker you become. Visiting your physiotherapist as soon as possible will help you to get on track with a tailored education and exercise program.


How long until I feel better?

With specific advice and a tailored exercise program, most people will notice some reduction in pain within 2-4 weeks. However, it will usually take a commitment to an exercise program over a number of months to regain adequate improvements in strength and movement patterns to consistently control symptoms and regain normal activity levels. The timeframe can vary significantly depending on the severity of the tendon problem, duration of the problem, previous interventions, level of muscle weakness or physical conditioning, other coexisting health problems and adherence with advice and exercise prescription. 


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Groin pain is a common and complex condition, caused by abnormal muscle forces acting on the joint at the front of the pelvis. There are several muscles that attach near this joint. Groin pain can be classified by which muscles are affected. These include adductor-related, iliopsoas-related, inguinal (or abdominal) related, pubic-related groin pain or hip-related groin pain. There may also be other causes of groin pain not covered by these five types. 

How do I know if I have groin pain?

Groin pain is often complex and can be difficult to diagnose. Pain may be experienced on one or both sides of the groin. Pain can sometimes also be experienced in the lower abdominals or at the front of the hips. Firmly touching the pubic bone at the front of the pelvis commonly makes the pain worse. Pain may also be made worse by crossing your legs, squeezing your knees together or when moving the affected leg away from the midline of the body (abduction). Pain is often aggravated by exercise such as running, kicking, performing sit-ups or change of direction activities.


How can physiotherapy help with groin pain?

Physiotherapy has been shown to be successful in treating groin pain, and most people with the condition make a full recovery when managed well over time. Commonly used physiotherapy treatments include helping you to manage your daily and sporting activities, advice and education, strengthening the abdominal and hip muscles, and improving range of motion of the hip by stretching and manipulation.


How effective is physiotherapy for groin pain?

Physiotherapy has been found to be a successful intervention for managing groin pain. Systematic review evidence shows that supervised active physical training results in a higher percentage of athletes returning to play than passive physical therapy treatments alone.


What can I do at home?

Take note of the activities that bring on your groin pain–this will help your physiotherapist. By avoiding repeated kicking or rapid changes of direction while running, you may find that this helps to prevent your groin pain from worsening.


How long until I feel better?

Once your groin pain has been diagnosed and a rehabilitation plan begins, the likelihood of a full recovery from groin pain is good, although this can often take three months or more.


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Osteoarthritis of the hip joint occurs when the smooth cartilage that covers the ends of our bones becomes brittle and breaks down. This can in turn cause joint inflammation and the formation of ‘bony spurs’ (outgrowths of bone) as the body tries to repair the damage. Osteoarthritis is not simply ‘wear and tear’ as has previously been thought.

What causes hip osteoarthritis?

The exact cause of hip osteoarthritis is unclear, but some risk factors have been identified. These include:

  • being overweight or obese
  • a family history of osteoarthritis
  • older age – people over 45 are more at risk
  • previous hip joint injury or significant trauma to the joint.

How do I know if I have hip osteoarthritis?

The symptoms of hip osteoarthritis can vary significantly from one person to the next. Some common symptoms include:

  • pain in the groin, buttock or at a point deep between the two
  • hip joint stiffness
  • grinding, rubbing or crunching sensation when moving the hip.

If you are experiencing any of these symptoms it is important that you consult your doctor or physiotherapist. They can diagnose your hip joint pain.


How can physiotherapy help with hip osteoarthritis?

Physiotherapy can help manage your hip osteoarthritis by providing treatments, as well as advice and education that help you manage your condition in the way that best suits you.

Your physiotherapist can assess your hip and identify particular muscles that may be weak. They can teach you specific strengthening exercises for these muscles. Strengthening the muscles around the hip joint will support and protect the joint. You may be given exercises to continue on your own at home, or you could be referred to a group exercise class or a hydrotherapy (water exercise) class. Hands-on techniques such as specific joint mobilisation or massage techniques can also assist with pain reduction. Together with other exercises, these can help you try to maintain as much joint motion as possible.

Your physiotherapist may also assess your balance and gait (the way you walk), and teach you exercises to help you walk well. If needed, they can teach you how to use a walking stick or crutches to help with walking.

Your physiotherapist is the best person to advise you about activities to avoid, sports participation, and techniques you can use to help minimise joint pain. Physiotherapists can also talk to you about managing your weight to minimise the pressure on your joints and, if necessary, can refer you to a dietician.


How effective is physiotherapy for hip osteoarthritis?

There is no cure for hip osteoarthritis but research shows it can often be managed effectively using exercise, weight loss and medications, with no need for surgery in many cases. Your physiotherapist is qualified to help you figure out the best type of exercise to do for your condition. The best available evidence indicates that exercise therapy (whether land-based or water-based) is more effective than no exercise in managing the pain associated with hip osteoarthritis in the short term.

There is some evidence for the benefits of manual therapy for people with hip osteoarthritis. Larger high-quality RCTs (randomised controlled trials) are needed to establish the effectiveness of exercise and manual therapies in the medium and long term.

There is little clear research evidence for other treatments such as TENS, ultrasound, laser or acupuncture for hip osteoarthritis.


What can I do at home?

It is important to maintain your regular exercise and physical activity, as much as your hip symptoms allow. Avoid activities and positions that bring on pain in the hip or that make the pain worse.

It is best to talk to your doctor about which medications are best for you to help manage your symptoms.

Some people find hot or cold therapy (such as a heat pack or ice packs) applied to the hip joint are helpful, but you will need to try a few different things and figure out what works best for you.


How long until I feel better?

Each person with hip osteoarthritis will have different symptoms, and will progress in a different way. It is important not to compare your symptoms to others, and to consult your doctor or physiotherapist about the best way to manage your condition.


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A total hip replacement is a surgical procedure where the ball and socket of the hip joint are replaced with artificial material. The ball at the end of the femur and the socket in the pelvis are replaced with a ball and cup made of metal, plastic, ceramic or a combination. An orthopaedic surgeon performs a total hip replacement, and the operation takes approximately an hour to an hour and a half. The surgeon cuts into the hip, removes the damaged bone and inserts the artificial joint, fixing it to the bone.

Why is a total hip replacement done?

A total hip replacement is usually only considered for people whose hip joints have been severely damaged, most often due to osteoarthritis, trauma or other joint diseases. A total hip replacement is recommended only after non-surgical interventions such as exercise, weight loss and pain medications have been trialled, and when the condition significantly limits a person’s ability to perform activities of daily life.


How do I know if I need a total hip replacement?

An orthopaedic surgeon will decide when a total hip replacement is the best intervention for you. Your physiotherapist or GP may refer you to an orthopaedic surgeon after trying other treatments (such as exercise, weight loss and pain medications).


How can physiotherapy help following a total hip replacement?

Physiotherapy is an important part of rehabilitation after a total hip replacement. You will see a physiotherapist during your stay in hospital. They will teach you exercises to do while you are in bed, and while sitting and standing, to ensure you are working the muscles around the hip and thigh. They will also teach you how to get in and out of bed, how to walk with a frame or crutches, and give you precautions and advice for at home. If needed, they will teach you how to walk up and down stairs.

The physiotherapist will give you exercises to continue at home. It may be recommended that you keep seeing a physiotherapist after you go home, or attend an exercise class or hydrotherapy (exercise in the water) class. Alternatively you may be asked to continue with the exercises and gradually increase your walking on your own at home.


How effective is physiotherapy after a total hip replacement?

Studies have shown that people who complete exercises after a total hip replacement may have significant improvement in functional activities of daily living, walking, quality of life, muscle strength and joint range of motion compared with people who do not.


What can I do at home?

The physiotherapist who sees you in hospital will give you specific exercises to continue with each day at home. In addition, you should take regular walks each day, gradually increasing the distance. Returning to work and sport should be done only after consulting with your physiotherapist and orthopaedic surgeon.


How long until I feel better?

Recovery from a total hip replacement varies from person to person. Most people will need to use crutches for 4–6 weeks following surgery. You will be able to walk without crutches when you can walk without a limp, pain or swelling, and are confident you can manage on your own.

An artificial hip never feels quite the same as a normal hip, and it is important to look after it in the long term. 


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