Getting to the bottom of the problem – Lateral hip pain

Lateral hip pain is a very common complaint that is reported in roughly 1 in 4 women over the age of 50, and can be a difficult condition to treat due to the multifactorial aspects impacting on individual presentations.  Lateral hip pain can interfere with physical activity, but also with quality of life, activities of daily living and sleep quality. We now know that the primary pathology contributing to nociception in this condition is tendinopathy of the gluteus medius and/or minimus tendons, with potential for associated changes through the bursae and iliotibial band. To optimize outcomes for patients presenting with lateral hip pain, it’s important to understand the aetiological factors and impairments that are reported within the latest evidence. However, the ultimate key for patient-centered care is to understand how these factors relate to our patient, their concerns for day to day activities or physical activity and goals. This is what we aim to achieve at Inspire by creating a shared decision making process, and involving our multi-disciplinary team as deemed necessary.

Patients presenting with this condition often report pain and tenderness over the side of the hip, and they may also describe radiating pain down the lateral thigh. They may suggest aggravating factors such as side sleeping, climbing stairs, long or fast walks, walking up an incline, or activities that involve standing on one leg. One of the most commonly reported aggravating factors that we see with our clients are poorly performed clam exercises! It is very beneficial to diagnose this condition early, before lumbo-pelvic compensations are prolonged, but also important to assess for all differential diagnoses such as hip osteoarthritis/articular pathologies, lumbar spine/sacroiliac joint referred pain and pelvic pathology. Failure to identify the underlying diagnosis may result in insufficient rehabilitation.

 An accurate diagnosis of lateral hip pain is best achieved with a combination of tests;
    • Direct palpation of greater trochanter “the jump sign”
    • SLS: single leg stance, reproducing lateral hip pain within 30 seconds
    • FADER: Flexion, adduction, external rotation of the hip
    • FADER-R: Resistance added to the FADER position
    • FABER: Flexion, abduction, external rotation of the hip
    • ADD: Passive hip adduction in side lying
    • ADD-R: Resistance added to the ADD position in side lying 

The most important part of these tests is consistent questioning around whether the test has reproduced the patients exact pain that they have been experiencing.

Imaging may be used with complex presentations, most commonly ultrasound and magnetic resolution imaging (MRI). However, MRI changes are commonly found in asymptomatic patients so results must be clinically correlated. Exercise and load management are the cornerstone of long term solutions for tendinopathy. Corticosteroid injections can provide short-term pain relief in most cases, however, education plus exercise has been shown to results in better global improvements over long term follow ups within the research. When used, CSI should provide a pain-free window in which the patient can engage with an effective rehabilitation program involving targeted physiotherapy treatment, load management and functional strengthening through the hip abductors.

A crucial aspect of treatment is advice and education around day to day postures and stretches, some of which may be contributing to the prolonged symptoms. Education is based around avoiding positions that create a moment of hip adduction, as this creates compression of the gluteal tendons and trochanteric bursa underneath the tensile loading of the iliotibial band. This may include movements such as sitting with legs crossed, stretching ITB or piriformis, clam exercises or walking with young children resting on one hip. It will make a large impact on duration of symptoms if these movements can be modified or adjusted accordingly. Other factors that may also play a role in aggravation of symptoms can be sleeping on the affected side, which can be modified to supine sleeping with pillows underneath the knees or a ¼ turn into prone with pillow support. Further advice to adjust cadence, step length, stairs and hills may be needed for clients wishing to stay active throughout rehabilitation.

The cornerstone to positive long term outcomes in lateral hip pain, is addressing abduction strength and control in functional/relevant patterns. Exercise interventions are also guided by patient goals, whether the aim is to return to plyometric activity, running, or simply being able to walk upstairs without discomfort.  The basis of exercise therapy and load management is to enable progression from non-weight bearing to weight bearing, functional integration into gait and to include multi-directional control. Depending on patient goals, our approach at Inspire is to determine the best form of rehabilitation for each individual – whether it be hydrotherapy, reformer pilates, a home-based exercise program, or involving the assistance of one of our exercise scientists or physiologists. I believe that through a forensic approach to diagnosis, consideration of the latest evidence base, and involving a shared decision-making process throughout the treatment, we are able to deliver positive long term results consistently to our clients.

References:

Fearon, A. M., Cook, J. L., Scarvell, J. M., Neeman, T., Cormick, W., & Smith, P. N. (2014). Greater trochanteric pain syndrome negatively affects work, physical activity and quality of life: a case control study. The Journal of Arthroplasty, 29(2), 383-386.

Grimaldi, A., Mellor, R., Nicolson, P., Hodges, P., Bennell, K., & Vicenzino, B. (2017). Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain. British Journal of Sports Medicine, 51(6), 519-524.

Mellor, R., Bennell, K., Grimaldi, A., Nicolson, P., Kasza, J., Hodges, P., ... & Vicenzino, B. (2018). Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. British Journal of Sports Medicine, 361.

Woodley, S. J., Nicholson, H. D., Livingstone, V., Doyle, T. C., Meikle, G. R., Macintosh, J. E., & Mercer, S. R. (2008). Lateral hip pain: findings from magnetic resonance imaging and clinical examination. Journal of Orthopaedic & Sports Physical Therapy, 38(6), 313-328.