Hip

Hip impingement syndrome is a pre-arthritic condition of the hip joint that develops as a consequence of irregular anatomical relationships between the head and neck of the femur and the acetabulum (a ball-and-socket joint). Hip impingement syndrome is a condition that oftentimes goes unnoticed; it is a common cause of limited mobility and pain in the hip joint, especially among the sports-active younger male population and among middle-aged women. Hip impingement syndrome develops because of a long-term condition where the front or the outer part of the neck or head of the femur continuously hit the adjacent edge of the acetabulum (a ball-and-socket joint) due to congenital anatomical anomalies.

Some common anatomical anomalies that cause hip impingement include an improperly healed femoral neck fracture, avascular necrosis of the femoral head in childhood (Perthes’ disease), subacute – possibly asymptomatic – slippage of the femoral head, and a disorder in the development of the acetabulum. There are two main types of the hip impingement syndrome. Type I – the femoral type of impingement or “cam impingement,” which is a consequence of the irregular shape of the femoral head. When bending and internally rotating the hip, the convex passage of the outer anterior part of the femoral head, comes into close contact with the upper anterior edge of the acetabulum (a ball-and-socket joint) and labrum.

Shear forces and repetitive movements, damage the joint surfaces. Type II – the acetabular type of impingement or “pincer impingement,” is a consequence of retroversion (tilting back) and excessive deepening of the acetabulum (a ball-and-socket joint), which during the flexion of the hip causes the anterior edge of the acetabulum to meet the anterior edge of the femoral neck. Consequently, the anterior part of the labrum tears and suffers degeneration, and later the cartilage of the anterior part of the acetabulum is damaged.

What is typical of hip impingement syndrome is pain and limited mobility of the hip joint. It often appears in the active population of the young and middle-aged (15-45 years). Groin pain that appears during specific movements when putting stress on the hip is typical of the condition.

The pain appears most often when bending the hip under specific angles in activities such as running, cycling, stepping up, and forcefully turning. The pain can be dull in nature (due to cartilage injury), or it can be intense and stabbing (due to labrum injury); it may radiate down the anterior part of the thigh and all the way to the knee. During the later stages of hip impingement syndrome, even lifting the leg or walking while performing everyday house tasks may cause a sharp pain to appear. In cases of advanced condition that consequently includes joint arthrosis, other movements of the hip joint may be painful, for example, a combination of flexion, external rotation, and hip abduction.

To confirm the diagnosis, it is recommended for the orthopaedic specialist to perform clinical testing of the hip joint and magnetic resonance imaging (MRI). Clinical testing is positive when it is painful for the hip that is bent at an angle of 90 degrees to perform the manoeuvre in the direction of internal rotation. X-ray imaging is also recommended.

In the beginning, the treatment should be conservative and exclude the activities that cause pain. It is recommended as part of manual therapy to perform articulation techniques on the hip along with exercises that help maintain mobility of the hip joint and eliminate muscle imbalance. It is important to strengthen the muscles that enable adequate hip joint stability, which lessens the stress on the labrum of the acetabulum while walking.

Surgical treatment is recommended when the conservative regime of treatment does not improve the symptoms of hip impingement syndrome in the course of 3 to 6 months.

The main goal of surgical treatment of hip impingement syndrome is to remove structural limitations that prevent the movement of the hip joint in the direction of flexion and internal rotation, remove and reattach the injured – possibly degenerated labrum – and prevent further peeling of the cartilage surface and the subsequent joint cartilage wear.

Piriformis syndrome (syndrome of the ‘pear-shaped’ muscle) presents itself as sharp pain around the hip and lumbar part of the back; the pain may radiate even down the leg.

Piriformis syndrome is the most common sciatic nerve neuropathy that is classified as entrapment or tunnel neuropathy, characterised by the discrepancy between the diameter of the nerve fibres and the size of the nerve canal that runs between muscles and bones. The pain is caused by the narrowing of the bone-muscle canal where the sciatic nerve runs, which is caused by the increased tension of the piriformis muscle.

The reason for excessive contractions of the piriformis muscle is mostly weakness of the hip stabilizers and external hip rotators, whose function begins to take over the piriformis muscle. A common cause for the development of piriformis syndrome is sitting for too long, hyperlordosis of the lumbar spine, abnormally enlarged piriformis muscle, scarring after trauma, congenital anatomical abnormalities of the nervous system, intensity of sports activities, spine and hip joint pathologies, and injuries to the connective tissue in the pelvic region.

Piriformis syndrome is common among runners, cyclists, weightlifters, “gym rats” etc., who do not dedicate enough time to stretching the hip adductors and specific strengthening of the abductor muscles. The cause of piriformis syndrome is often poor mobility of the joints between the sacrum and the pelvis, which leads to compensatory changes in walking and running and consequently to the increased strain on the hip

Symptoms of the piriformis syndrome are similar to those caused by numerous degenerative changes of the spine, for example disc herniation, degenerative changes of the lumbar vertebrae and facet joints, lumbar spondylosis, etc.

The piriformis syndrome is accompanied by intense pain in the area of the loins and sacral spine; the pain may also radiate down the leg and is usually most intense in the buttocks. What is typical of piriformis syndrome is that with palpation we can feel the slight stiffness of the muscle. Loss of strength in abduction and external rotation of the hip joint is typical. Other characteristic symptoms include a tingling sensation in the back of the leg, pain when sitting for a long time, and pain in the back and buttocks when standing up. The symptoms usually worsen while sitting and walking a longer distance.

Making a clinical diagnosis is difficult since the symptoms are typical of numerous pathologies in the lumbar and sacral intestinal area. A differential diagnosis that eliminates the remaining pathological conditions is used to confirm the piriformis syndrome. An ultrasound examination of the piriformis muscle is a reliable diagnostic method since there is a strong correlation between the morphological change of the piriformis and the piriformis syndrome.

The treatment of piriformis syndrome is conservative, using adapted physical therapies and kinesiological exercises that eliminate the causes for the development of the piriformis syndrome. The conservative treatment programme includes exercises that improve the mobility of the hip joint and techniques to release myofascial tissue.

Deep tissue massage, transverse friction massage, and a gentler application of shock wave therapies are effective when treating piriformis syndrome. It is important to eliminate potential muscle imbalances and assess and improve the biomechanics of the basic movement patterns.

The methods of surgical treatment are used only rarely; a common indication for surgical treatment is the piriformis syndrome caused by the intervertebral hernia.

Surgically inserting a prosthetic implant of the hip joint is one of the most common surgeries in modern orthopaedics with a high success rate of the intervention. The hip joint is surrounded by the joint capsule, which produces the synovial fluid, reduces friction, and prevents hip wear with its lubricating effect. Anatomical changes in any part of the hip, caused by injury, inflammation or surface wear, affect the mechanics of the entire hip that is functionally affected.

A hip prosthesis is an artificial hip joint, constructed of metal materials, that the surgeon inserts in the place of the real hip joint during surgical treatment in the event of advanced cartilage wear and/or arthritis of the hip joint. The impairment of the hip joint that is treated by hip arthroplasty is most often caused by joint cartilage wear, which is the most common reason for hip pain after 50 years of age. Early cartilage wear can also be caused by various inflammations (rheumatoid arthritis, gout, psoriasis), certain developmental impairments (congenital hip dislocation, Perthes’ disease, slippage of the femoral head), or traumatic injuries that the hip joint endures during the long years of continuous action.

In the early phases of hip cartilage wear, the symptoms are mild. They only include pain in the joint that at first only appears when starting to walk or after walking for a long time. It can also be accompanied by the gait cycle disorder (limping).

During the advanced phase of the condition that affects the joint cartilage, the pain is also present at rest. It is often accompanied by the limited mobility of the hip joint. Poor mechanics of the hip joint, caused by cartilage surface wear, leads to a reduced walking ability and difficulties managing essential life tasks. Above all, it occasionally causes high-intensity pain. Total hip arthroplasty is recommended when cartilage wear causes intense pain at rest that needs to be alleviated with analgesics and pain that causes mobility limitations when performing everyday tasks.

During the first phase, the pain that is a consequence of cartilage wear is treated with conservative techniques of special exercises and physical therapies. In the initial phases, the pain that is a consequence of hip cartilage wear appears only with specific moves and with greater loads, which is why we first apply special exercises to strengthen the muscle tissue and therefore reduce the stress on the cartilage surfaces of the joint. At the same time, we increase the pain tolerance and extend the time until surgically inserting the prosthetic implant of the hip joint. Hip joint replacement is generally recommended as late as possible since the average lifespan of an artificial hip is limited to 20-25 years.

Before surgery, the rehabilitation should be carried out holistically since improving general physical fitness and local muscle capacities accelerates the soft tissue regeneration mechanisms. Most patients may begin with the usual physical activity in the period of between six to nine months after surgically performing a total hip joint replacement.  Postoperative rehabilitation after total hip joint replacement is finally completed in the period of between nine to twelve months; it should be carried out in the progressive regime of special exercises with physical therapy in the first postoperative months and then continued with professionally guided individual training in the second phase of rehabilitation.

• Performing conservative preparations for surgical treatment.
• Preoperative rehabilitation should be carried out holistically since improving general physical fitness and local muscle capacities accelerates the soft tissue regeneration mechanisms.
• Postoperative rehabilitation after total hip joint replacement is finally completed in the period of between nine to twelve months; it should be carried out in the progressive regime of special exercises with physical therapy in the first postoperative months and then continued with professionally guided individual training in the second phase of rehabilitation.

Hip dislocations are divided into traumatic dislocations, which are a consequence of accidents, suffering blows or falling, and spontaneous hip dislocations in children or hip dysplasia, which is one of the most common abnormalities in the development of extremities. This condition is described in detail on our website under the description of hip dysplasia.

The most common cause of traumatic hip joint dislocations are car accidents. Dislocations occur when the knee forcefully hits the dashboard when colliding with an external object. The force of collision pushes the hip backward, which causes the femoral head to move posteriorly outside of the acetabulum joint. Traumatic hip dislocations are common also when falling down the stairs and when falling from a height. Traumatic hip dislocations are often accompanied by pelvic bone injuries and injuries to the femur, injuries of the head or upper extremities. Damage to the articular surfaces of the hip joint may also occur. The most common fracture that accompanies hip dislocation occurs when the femoral head posteriorly hits the edge of acetabulum – posterior hip dislocation with acetabular fracture.

Traumatic hip joint dislocations are often accompanied by other injuries to the skeleton and skeletal structures of the hip, which is why it is necessary to undergo clinical examinations of the body at the doctor’s office immediately after the injury. Moreover, it is necessary to perform x-ray imaging of the hip joint and other injured parts of the body. It the hip joint dislocation occurs in isolation, then the femoral head is repositioned to its natural position under anaesthesia. If the dislocation is accompanied by deformations of joint surfaces, it is necessary to remove the loose bodies of bone or cartilage.

Traumatic hip dislocations may be accompanied by severe complications, for example of nerve fibres, which occurs in 10% of the cases; vascular injuries, which can cause osteonecrosis (bone decay beneath the joint cartilage due to circulatory disorders); or damage to the cartilage surface.

Complete rehabilitation of a traumatic dislocation usually lasts between 2 and 3 months, however, if it is accompanied by long bone fractures, this prolongs the rehabilitation. During rehabilitation, it is important to establish good stability of the hip joint and adequate control of mobility, especially in terms of basic functional movements of the hip joint. Moreover, it is necessary to strengthen the muscles, which often atrophy after a hip injury, and prevent the development of muscle imbalance.

It the hip joint dislocation occurs in isolation, then the femoral head is repositioned to its natural position under anaesthesia.

If the dislocation is accompanied by deformations of joint surfaces, it is necessary to remove the loose bodies of bone or cartilage.

Complete rehabilitation of a traumatic hip dislocation usually lasts between 2 and 3 months, however, if it is accompanied by long bone fractures, this prolongs the rehabilitation.

During rehabilitation, it is important to establish good stability of the hip joint and adequate control of mobility, especially in terms of basic functional movements of the hip joint. Moreover, it is necessary to strengthen the muscles, which often atrophy after a hip injury, and prevent the development of muscle imbalance.