WHY DOES MY HIP HURT?
Maintaining a good range of motion throughout all the joints of the body is really important as our jobs or lifestyles change and as we age. We use our hip mobility all the time! When we walk, climb, jump, bend forward, crouch down on the floor, clean, play with our children, play sports, get in and out of the car- like we said, ALL THE TIME.
As osteopaths, we see many people with various presentations of hip pain;
Bursitis
Tendinopathy (most commonly of the gluteal muscles)
Osteoarthritis
Labral Tears
Muscle Hypertonicity causing pain or altered mechanics
MAJOR MOVEMENTS OF THE HIP:
The hip is a ball and socket joint consisting of the head of the femur (ball) sitting in the acetabulum of the hip (socket). Like the shoulder, this type of joint allows for a wide range of motion around an axis.
The hip joint flexes, extended, abducts, adducts, medially and laterally rotates and horizontally adducts and abducts. This is opposed to say, a knee, that flexes, extends and has some internal and external rotation.
We could go into vast detail of all the muscles that contribute to the motion and stability of the hip joint. But let’s focus on some of the major ones, that you may already know of or have been instructed to “strengthen” or “stretch” before.
The Gluteus Maximus
The “glute max” is arguably one of the most important skeletal muscles in the body. The glute max is basically our “butt”!
It is a very large, powerful muscle - the LARGEST in our bodies in fact.
It is responsible for hip extension.
Hip extension involves bringing the leg backwards. It is crucial to many of our everyday movements like our posture, walking or standing up from sitting. Without hip extension and the glute max, we wouldn’t even be able to stay upright!
If we have an underdeveloped, lazy or otherwise inefficient glute max, we may develop lower back pain, glute pain, hip pain, pelvic instability, tight hamstrings or knee pain. Conversely, we find that strengthening the glute max will often contribute to improving postural endurance, lower back pain, hip or knee pain and pelvic stability.
Gluteus Medius
The “glute med” is a smaller muscle, also contributing to our “butt”. The glute med is smaller than the glute max, but when dysfunctional it can really cause some grief!
The glute med is responsible for abduction of the hip and pelvic stability in a single leg stance.
That is, the glute med keeps our pelvis stable during our gait cycle. Think about how a model would walk down a runway, swinging their hips from side to side. That in fact, is exactly what we don’t want!
That drop to the outside of the hip when walking can increase pressure on the outside tissue of our hips. This can lead to conditions such as bursitis or tendinopathies causing pain on the outside of the hip. The change in the angle of the hip during gait can also cause malalignment through our knees, causing knee pain or instability.
These are common complaints- you may have even experienced them yourself! Strengthening the glute med will assist in pelvic and hip control, decreasing the pressure put through those tissues and joints.
Piriformis
The piriformis runs from the front of the triangle bone at the base of the spine (the sacrum) and inserts into the back of the hip.
It controls external rotation of the hip.
It is very important in stabilising the pelvis and sacroiliac joints or “SIJ”. The sciatic nerve runs through or under the piriformis. As a result, a tight piriformis may contribute to “sciatic type” pain.
Iliopsoas
The iliopsoas consists of two muscles- the psoas and the iliacus. The psoas attaches from the lower back, travels down the trunk to merge with the iliacus that originates from the inside of the pelvis and attaches to the inside aspect of the upper femur. We can’t see this muscle as it lies very deep in our bodies.
The psoas is involved in trunk control and with the iliacus, activates hip flexion.
Hip flexion is the action of bending the hip at the front- that is, bringing the knee towards your chest. We need hip flexion to lift our legs - like when we walk or climb!
What many of us do not realise is that when we are sitting, we are in passive hip flexion.
Having “tight hip flexors” is extremely common, because so much of what we do in our daily lives involves sitting. When a muscle is at rest in a shortened position, it can become short, tight and even weak.
A tight iliopsoas can contribute to lower back pain, a “sway” back posture, tightness in the hip, weakness in the glute max (oh no!), hip or knee pain.
What are common causes of hip pain? How do you know if hip pain could be serious?
Let’s run through some of the most common painful hip conditions:
BURSITIS:
Trochanteric bursitis occurs when inflammation develops in the bursa (fluid-filled sack) that sits on the outside of the hip, under the tendons of the gluteal muscles.
This can occur as a result of direct trauma to the area, activities that may be repetitive in nature increasing strain through the tendons overlying the bursa (climbing, standing), deconditioned muscles leading to poor hip and pelvic control, osteoarthritis or underlying inflammatory conditions.
Bursitis often presents as pain on the outside of the hip, tender to touch, worsening of symptoms with activity and painful to lie on the affected side.
TENDINOPATHY:
Most commonly occurring in the gluteus medius and minimus tendons (the connective tissue attaching the muscle to the bone). This can present similarly to bursitis given the close proximity of the tissues and the similar causative and aggravation factors.
Tendinopathies typically develop due to weakness in the muscles increasing the load on the tendons. This causes pain, which further weakens the muscles and can lead to pelvic instability. A vicious cycle!
20-25% of post menopausal women will suffer from a gluteal tendinopathy- it is believed to be related to oestrogen’s effect on tendon metabolism.
Clinical examination may find it difficult to differentiate between bursitis and gluteal tendinopathy, hence ultrasound imaging will often be recommended.
OSTEOARTHRITIS:
Commonly known as wear and tear, osteoarthritis is the most common form of arthritis. It is a degenerative disease causing the surface cartilage of a joint to wear away, eventually leaving bone exposed beneath it.
Normal, healthy cartilage acts as padding in the joint. When it deteriorates, it becomes rough and can contribute to pain in the associated joint.
Symptoms include:
Discomfort and stiffness in your groin, buttock, or thigh upon waking.
Pain when putting on shoes from a seated position- this is hip flexion!
Pain flares up when you’re active, and calms when you rest.
Loss of flexibility and less range of motion in the hip.
You may feel a grating sensation when you move.
Swelling stiffness and warmth in the hip area.
Common causes:
A family history of the disease increases the likelihood of developing osteoarthritis.
Osteoarthritis usually goes hand-in-hand with aging, so older people and the elderly are more likely to have symptoms.
Very overweight and obese people are more likely to have osteoarthritis.
An injury can lead toward developing osteoarthritis, even years after it occurs.
HOWEVER- osteoarthritis DOES NOT MEAN PAIN. Many people will have osteoarthritic joints - hips, knees, backs- but will cope with the change in cartilage health, maintaining good function and suffering minimal to no pain.
WHY DOES MY HIP HURT WHEN I SLEEP?
The trochanteric bursa and gluteus medius tendon are the main structures causing pain during sleep, especially pain on the outside of the hip. One possible explanation is the sleeping position and pressure applied to the affected area. When lying on the side, the pressure exerted on the hip can irritate the trochanteric bursa and gluteus medius tendon, leading to pain and discomfort.
Additionally, certain sleeping positions may exacerbate underlying conditions such as hip bursitis or glute med tendonopathy. Inflammation or degeneration in these structures can make them more sensitive and susceptible to pain, especially when subjected to pressure or friction during sleep.
Moreover, reduced movement during sleep can contribute to increased stiffness in the hip area. Lack of mobility and prolonged immobility can cause the bursa and tendon to become stiff and inflamed, leading to pain sensations when awakening.
It is also worth noting that pain experienced during sleep may not be solely attributed to the bursa or tendon itself. Other factors like muscle imbalances, joint problems, or referred pain from nearby structures can contribute to nighttime discomfort in the hip region.
If you have pain on the outside of your hip during sleep, try to sleep on your back if possible. However, proper treatment and rehabilitation of the hip is crucial in alleviating the pain long term.
IN GENERAL, HOW DO WE ENSURE OUR HIPS STAY AS HEALTHY AND HAPPY AS POSSIBLE?
Movement is key! Use it or lose is as they say.
At the beginning of this article we looked at ALL the movements available at the hip. As a ball and socket joint, it is designed to move A LOT.
As we age, if we move less OR move in a narrower range of motion, we may put more load through various aspects of the joint. This may contribute to an increase in wear in cartilage through a particular aspect of the joint, compared to if the joint was moved more variably.
Muscle tension and strength also plays a role in joint support and function. In the hips, if we maintain good glute strength, it means we stay more supported in activities such as walking, bending and standing for long periods. This will ensure our mechanics are moving as optimally as possible, reducing the likelihood of tendinopathies, bursitis, tight muscles or early onset osteoarthritis.
Resistance exercise, a mixture of weight bearing and non weight bearing activities, a good diet and hydration, are other parts of our lifestyle that can improve our tissue and joint health!
COME AND SAY HI!
If you suffer from hip pain, we are here to help you. Osteopathic treatment can assist in the correct diagnosis of the cause of your pain and provide treatment and an individually tailored management plan to alleviate pain and get your hips back to being as healthy and happy as possible!
Author: Dr Madeleine Goodman, Osteopath. Summit Osteopathy 2021