Hip impingement: getting active people moving again

Treatment solutions to get active people suffering from hip pain moving. Janet Snell reports

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Hip impingement: love acticity but it doesn't love you (photo: Glen Robbins and Genevieve Randall)

As a physio with a background in the fitness industry, Glen Robbins has developed a special interest in treating problems that stem from exercise, particularly lower limb pain.

Since qualifying in 2005 he has seen a steady rise in the number of patients diagnosed with symptomatic hip impingement and he is keen to promote awareness of the common condition which he believes is sometimes a ‘blind spot’ for some clinicians.

‘It should be on everyone’s radar,’ he asserts. ‘The coverage of Andy Murray’s issues with his hip has helped raise awareness, but many patients may not be getting the early diagnosis and rehab programmes that they should.’

Up until about 20 years ago people were diagnosed with ‘non-specific hip pain’ and told they were probably developing arthritis and they would have to wait until they were old enough to have a hip replacement. But technical advances mean investigations can show that many of these patients have underlying bony morphological changes, for example Femoroacetabular Impingement. 

Active people are the most likely to suffer hip pain resulting from symptomatic FAI syndrome and there are three main subgroups:

  • Young people involved in competitive sport (usually involving rotational loading) from an early age (normally very active between
  • 10-15 years when the bony growth plates are forming)
  • Slim active females aged 25-35
  • Middle-aged men and women engaging in vigorous gym workouts

Glen says: ‘The first group can include elite sportspeople playing football, tennis, rugby or hockey. The higher the level of sport, the higher the incidence of a cam presentation and the cam deformity has often been acquired over a number of years starting in childhood. Essentially it is a bony response to the stress placed on it.

‘The second group, which are the ones most likely to turn up at an ordinary MSK clinic, are females. They are regular gym-goers, exercising regularly and doing lots of squats and lunges. Often they have increased their training to get in shape for a special event like a holiday or a wedding, and then they experience onset of pain.

‘The third group may have had several years where they stopped exercising, perhaps because they were busy with children or careers, and then they return to high intensity interval training, marathon training, cross-fit or whatever.

‘Both of these latter groups will blame the pathology on their training, but often the risk factors have been there since they were teenagers.’

Catching the issue early is important, but when Glen first set up in practice with his partner Benoy Mathew their average patient had had to wait five to seven years for a diagnosis, seeing an average of three to five therapists. 

‘That’s improved now but it could still be better,’ he says. ‘If we start early enough, the condition may be managed conservatively and individuals can continue with exercise, for example by modifying the way they do a squat and the load that they put through their hip. 

‘People get obsessed with a perfect technique – knees and feet in line say – and many trainers, and even physios, promote that. But it can be detrimental to the hips if an individual has a lack of internal rotation because of a retroverted hip for example. 

‘Some small changes, like turning your feet outwards, reducing a trunk forward lean and limiting depth, can make a real difference.’

Glen and Benoy have delivered courses on FAI and dysplasia to around 2,000 people in 11 countries to date, using a ‘four layered’ approach to assessing the hip: walking and movement screening; soft tissue assessment; capsule and labrum assessment and finally the hip joint itself.

‘It’s important to leave the joint assessment until the end,’ says Glen. ‘Too many physios will jump in on the joint first, I was taught to do that at both undergraduate and postgraduate level but in symptomatic FAI clients it can be counterproductive. There’s often considerable irritation when people are symptomatic so if you go in and do a joint test, yes it will tell you the hip joint is part of the problem, but then you will not be able to do anything else for the rest of the assessment’. 

What is Femoroacetabular Impingement (FAI)? 

  • Femoroacetabular impingement (FAI) syndrome is a disorder of the hip. 
  • It is the result of an abnormal contact between the femur (thigh bone) and the acetabulum (the socket).
  • In the US surgery for hip impingement increased 1800% between 2003-2013 while in the UK it rose 442% (Reiman and Thorborg 2014)

‘We’ve designed a protocol and our approach to rehab is different in that we get people weight training after a period of activity modification and lower level training. It’s scary, even for me with a strength and conditioning background. I used to steer away from loading these clients in the gym, but if it’s done in a modified way and at the right time with specific bodyweight specific criteria, it works. As long as you have a good system in place there’s no reason why many of these clients should not return to a really high level of function.’ 

     

    Case study

    Genevieve Randall is a former Team GB synchronised swimmer with a history of bilateral hip pain attributed to FAI. Glen explains:  

    ‘Genevieve arrived at our clinic in 2018 and said she’d had an arthroscopy on her left hip in 2016 but the other hip had been managed conservatively. During the initial assessment she said her goal was to continue her training as a stunt woman but that pain was stopping her. On examination she had global weakness in the hip, glutes and hamstring. Treatment started with some manual therapy to improve mobility, relieve pain and release muscle tension, particularly in the adductors and the hip flexors. By the third session she was ready to start work in the gym on stability around the hips to regain strength, power and function. 

    ‘We used an innovative approach with Genevieve – blood flow restriction training. [There is some evidence to suggest that this can increase muscle hypertrophy during a resistance training programme (Lowery et al 2013)] We used it for four weeks with Genevieve and then introduced traditional strength training, but modified to avoid a hip flare-up. We gave her specific body weight-linked criteria and, as you’d expect with a former Team GB athlete, she hit her criteria really quickly. She then continued with a personalised strength and condition programme delivered by our personal trainer Ben Kilner, a trained physio with a history of Perthes disease and a special interest in hip rehabilitation. 

    A big part of treating these clients is education on what could irritate their condition. Genevieve has done really well with conservative treatment and has not needed surgery. Some people may need surgery but if managing the hip conservatively does reduce or eliminate the pain then that is certainly the first option to try.’

    More information

    References:

    Reiman, Michael & Thorborg, Kristian. (2014). Clinical examination and physical assessment of hip joint-related pain in athletes. International Journal of Sports Physical Therapy. 9. 737. 
    Ryan P Lowery, Jordan M Joy, Jeremy P Loenneke, Eduardo O de Souza, Marco Machado, Joshua E Dudeck, Jacob M Wilson (2014) Practical blood flow restriction training increases muscle hypertrophy during a periodized resistance training programme Clinical Physiology and Functional Imaging 34:4

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