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Being Hip to Hip Pain

Not much thought is generally given to our hips unless of course you are experiencing pain in this region. Often a client complaining of “hip pain” is actually experiencing symptoms originating from the low back or sacroiliac joint. How do I know this? Because the spine generally refers to the buttock (“glute”) while pain arising from the hip joint itself presents as groin pain. The other clue that symptoms are most likely coming from the hip is a very specific pattern of restriction in mobility in the hip joint itself referred to clinically as a capsular pattern.

The most common causes of hip pain are impingement and degenerative arthritis and they share many of the same characteristic symptoms:

-Stiffness or deep aching pain in the front or side of the hip or front of the upper thigh while resting.

-Sharp, stabbing pain when standing up from a chair, squatting, rising from a squat, running, "cutting," jumping, twisting, pivoting, or making lateral motions.

-Hip pain described in a specific location by making a "C" with the thumb and hand and placing it on the fold at the front and side of the hip, known as the "C-sign."

-Pain that most often starts gradually, but can also remain after another injury resolves.

-Pain that increases with prolonged sitting or forward leaning.

-Feeling less flexible at the hips, including a decreased ability to turn your thigh inward on the painful side.

Let’s take a look however, at how these conditions differ:

Hip impingement involves a change in the shape of the surface of the hip joint that predisposes it to damage. There are 2 types of hip impingement; they may occur alone or together.

“Pincer” impingement and “cam” impingement occur because of either abnormal angulation of the hip socket, or protruding bone or because the shape of the bone around the head of the femur—the ball at the top of the bone in the thigh—is misshapen. The overgrown bone or incorrect angle of the socket causes the labrum, a rim of connective tissue around the edge of the hip socket, to be pinched. Over time, this extra pressure to the labrum when flexing (moving the leg forward) leads to wear and tear that can cause inflammation and could result in a tear. If this condition persists, eventually the cartilage that lines the hip joint can become worn and form holes. Pincer impingement affects men and women equally; symptoms often begin early, appearing at any time between 15 to 50 years of age, while cam impingement affects men to women at a ratio of 3 to 1; symptoms often manifest during the teen years and 20s.

Osteoarthritis, the other typical cause of true hip pain, results when injury or inflammation in a joint causes the soft, shock-absorbing cartilage that lines and cushions the joint surfaces to break down. When the cartilage is damaged, the joint can become painful and swollen. Sometimes people with this degeneration describe a "crunching" sound when the hip joint is moved, caused by bone rubbing on bone.

What about pain in the side of the hip? This is extremely common, especially in middle aged women with or without a known injury. Again, this might have its origins in the low back or could be what is known as “greater trochanteric bursitis”. This is an irritation of the bursa, a fluid-filled sac that sits on top of the bony prominence at the most outside aspect of the thigh. The bursa acts as a cushion to decrease friction between the bone and muscles attaching to the bone but it can become irritated. The most common underlying cause of this condition is muscle imbalance.

Your doctor may order diagnostic tests to help identify any joint changes, including x-rays, magnetic resonance imaging (MRI), or diagnostic injections. Hip impingement can occur at the same time as low back, buttock, or pelvic pain, or from conditions such as bursitis or groin strain. The final diagnosis may take some time, especially when other conditions are present.

When an active person develops hip pain, but does not have severe joint damage, the recommended treatment is physical therapy (PT). PT interventions can help decrease pain, improve movement, and avoid the progression of hip dysfunction and the need for surgery.

For example, strengthening of the hips and trunk can reduce abnormal forces on the already injured joint or irritated bursa and help with strategies to compensate, while improving hip muscle flexibility and joint mobility can reduce pain with motion. Joint mobilization may help ease pain from the hip joint; however, these treatments do not always help range of motion, especially if the shape of the bone at the hip joint has changed.

Your PT should also consider your job and recreational activities and offer advice regarding maintaining postures that are healthier for your hip and activity modification to enable you to enjoy an active lifestyle.

Other Articles From Kim

Cycling In Comfort

Whether you are a competitive cyclist of just a weekend cruiser, proper bicycle fit is extremely important. Taking the time to properly adjust your bike will promote good posture and allow all muscle groups and joints to work appropriately. When the miles add up this will reduce your chances of muscle strain in the neck, back and legs.

Even if a patient casually mentions to me that they cycle on a regular basis, I’ll question him /her extensively about the bike itself. I want to know if they use a mountain, road, or ‘cruiser’ bike, as the position of the body varies with each. I ask about symptoms following a ride to try and zero in on possible adjustments that need to be made to the bike. Often, I’ll ask the patient to bring the bike to my clinic so I assess the fit first hand.

One problem I frequently see is the failure to adjust the seat high enough to permit full knee range of motion, which not surprisingly results in pain the area of the kneecap.

Sometimes though the fit itself is good, poor body awareness while riding can be a source of pain. An example of this is the tendency for people to jut the chin forward while riding. This forward head posture changes the relationship of the head to the neck, resulting in excessive muscle strain with common complaints of neck and trapezius pain or numbness and tingling in the arm(s). I suggest training yourself to keep your chin back (as if giving yourself a mild ‘double chin’) and using your eyes versus your head/neck to look ahead.

Those of us who are below or above the average heights for our gender may need to further customize the fit if all else fails. To download a Bike Fit Brochure, visit the American Physical Therapy Association’s website: http://www.moveforwardpt.com/tips/biking/

Healing… From The Inside

After trauma, injury or surgery it’s not unusual for people to experience loss of appetite. Anesthesia and other medications, pain and inactivity all tend to suppress the appetite. This creates a dilemma in that when you most need nutrients from food to help your body heal, you’re just not interested in eating.

According to the Hospital for Special Surgery in NYC, NY your calorie needs are now greater than usual because your body requires energy from nutritious foods to fuel the healing process. You will need to consume about 15-20 calories per pound (using your current body weight). If your overall nutritional needs are not met, body tissues such as muscles and ligaments will begin to breakdown. This will compromise healing and may prolong your recovery period. Yes, there are supplements, but I know of something better.

It’s called living foods.

First, a little history…
Various peoples around the world have preserved their food out of necessity using a process of lacto-fermentation. Granted, not the most appealing name, but the result is magic none-the-less! “Cultured foods” are the result of this fermentation and are known to be some of the most nutritious substances on the planet.

Basically lacto fermentation happens when Lactobacilli, good bacteria found naturally in foods, converts their starches and sugars into lactic acid, a natural preservative that inhibits the growth of harmful bacteria. This process creates an amazing probiotic. It also starts the process of digestion to unlock additional nutrients (such as enormous amounts of Vitamin C) allowing our bodies to maximize absorption.

All health starts in the digestive tract thanks to predominant cells called Enterocytes. Even though they only live for a few days, these little work-horses enable the final stages of absorption and digestion. And they multiply in the presence of cultured foods!

Cultured foods can also reduce the body’s inflammatory and allergic responses by stimulating the adrenal glands through large amounts of vitamins B and C that become bio- available as these foods are digested. This support of the adrenals is essential to avoid “adrenal fatigue” that can result in chronic pain and exhaustion. Desirable to avoid at any time, but especially when you’re already not on your game!

Even if someone has no interest in food, they are usually motivated to drink liquids to avoid the complications of dehydration. The fermented drinks ‘kefir’ (pronounced KEE-fur) and ‘kombucha’ (kom-BOO-cha) are tasty and easy to digest options.

Yogurt is a cultured food but nutritionally pales in comparison to kefir. Think of kefir as a more nutritious, slightly bubbly, pourable version of yogurt and you get the picture. While yogurt has only 7-10 strains of good bacteria, kefir has between 30 and 55! No wonder kefir originated from a Turkish word meaning “good feeling”! I use Kefir made from almond milk (because of its high calcium content) in my morning smoothie to start the day off right.

Kombucha is a fermented tea made from a symbiotic culture of bacteria and yeast combined with tea and sugar. Not to worry in regards to the sugar; the culture itself consumes it, leaving a refreshingly tart quality likened to sparkling apple cider. Reach for it in the afternoon for a healthy alternative to soda.

Sauerkraut and pickles made the “old-fashioned way” along with the spicy Korean veggie known as ‘kimchi’ are all examples of cultured veggies. I am discovering delicious ways to ferment tomatoes, beets, carrots, broccoli, cabbage, kale, and chard that perk up any meal. These guys, in combination, provide lots of calcium along with Vitamins A, C, K and E that are essential for rebuilding tissue. Culturing veggies is super easy and requires no boiling, nor heating; a plus for those who aren’t a fan of cooking.

If you are interested in changing your health contact Nourishme in Ketchum or the Sustainability Center in Hailey. Both offer classes and you can try their hand-crafted cultured foods. You can also learn more by visiting the website CulturedFoodforLife.com. I gratefully applaud Donna Schwenk for sharing her knowledge and passion in her book Cultured Food for Life.

Stop Nighttime Pain, and Improve Your Sleep

Physical therapists are often consulted by patients whose chief complaint is of pain that keeps them awake at night. Frequently, the patients describe a vicious circle of pain creating fatigue, but of being unable to rest comfortably. Research confirms that a very complicated scenario exists between sleep and pain resulting in a loss of deep REM sleep.

Not surprisingly, many people ask what brand of mattress or pillow is best for relieving pain. The average consumer is bombarded and often confused by the claims of companies associated with the sleep industry. The degree of firmness experienced by a person will vary according to their height, weight and the material used in the construction of the mattress.

One that is too firm may cause unnecessary pressure on joints since the hips and shoulders should be permitted to sink in to some degree. Conversely a mattress that makes one feel as if they are caught and trapped in a depression all night is too soft. I recommend that a person lie down on a potential new mattress for a minimum of 10 minutes in their preferred sleep position as the choice is personal and subjective based on comfort and support.

One third of our lives is spent in bed, and a good night's sleep sets the tone for the following day. Studies show that sleep deprivation results in impaired judgment, delayed reflexes and an increase in the number of industrial and motor vehicle accidents. Sleep deprivation also impairs the immune system, and can result in weight gain and depression.

Pillows can be used creatively under or behind the body to help alleviate stress on joints. For example, patients with shoulder pain who wish to sleep on their painful side can place a pillow along their trunk with the top of the pillow at the armpit level. This effectively creates a depression at the shoulder because the body weight is now dispersed over a much wider area.

Those who suffer from neck/jaw pain, headache or upper extremity numbness/tingling need to be instructed to place the pillow so that the neck is properly supported (what I call 'swaddled') so that gravity is unable to pull the head forward into the fetal position.

I've had patients who report that while their low back pain during the day is minimal or non-existent, their morning pain is unbearable. Further questioning reveals that these folks are often stomach sleepers or that they adopt a 'hybrid' position of being partially prone and partially side-lying.

Both of these kinds of sleepers can be helped enormously by the use of a pillow under the abdomen /pelvis in their preferred position. I've found this to be especially helpful in those patients with spondylolisthesis and osteoarthritis as the pillow helps prevent the lumbar hyper-extension that usually gets them into trouble.

So how can something as simple as a change in pillow placement have such a huge impact on a good night's rest? Within our tissues there are mechanoreceptors that can become especially irritated from inflammatory processes. These receptors sense joint and tissue positions and relay this information to the brain. There are several types of mechanoreceptors, which is why some people complain of pain and stiffness after a prolonged sleeping posture, and others will complain of pain only as they begin to move (i.e. rolling over in bed).

Though it is sometimes difficult to convince a person who is suffering, this system is actually a good thing - it prevents further tissue or joint damage/irritation. Remember pain is just the messenger, and pillow placement can help alleviate the pressures creating the signal.

While night pain can be associated with serious medical conditions, if it is mechanical in nature it can often be relieved with just a few adjustments to your sleeping habits. Patients can be surprised when sleep posture is addressed at their very first PT visit, and are often grateful for having been empowered with the knowledge to take the first steps along their path to recovery.