Buzzing in some circles of physical therapy is the idea of developing an annual PT wellness visit. This would be the PT equivalent to the annual physical. The research basis of the profession and involvement in military and professional sports, uniquely posits PTs as, not simply rehabilitation specialists, but experts in reducing injury risk. This annual visit would allow PTs to further the dream of helping maintain wellness before injury or decline could occur.
PTs already do this in the geriatric population, as experts in identifying specific falls risk factors and reducing them. Physical therapists treat a wide variety of impairment across the lifespan, but the majority of Americans will not see a PT until they are close to retirement age. What if patients could see a PT years before? What would be assessed in an annual visit and would it translate into better function years down the road?
As PTs have emerged as the specialists in preventing falls in the elderly, treating low back pain, and rehabbing patients after total joint replacement, hip function is a recurrent topic. As the profession has moved toward the standards of evidence based practice, there seems an endless amount of data on the deep gluteal hip stabilizers. Proper function of these muscles is now considered vital in the best rehabilitation of a variety of movement related dysfunction and injury.
My name is Dr. Allan Buccola, physical therapist and owner of Impetus Physical Therapy in Greensboro, NC. This post will discuss the importance of hip strength across the lifespan, and describe some common injuries that are directly related to hip weakness. I hope by the end of this read, you'll agree that periodic assessment of the hip should have a place in the wellness visit for all people.
Teens and Young Adults: ACL, Meniscus, and Runner's Knee
In athletic populations, these injuries are common enough to have name recognition with high school to professional level sports fans. Although a strong proportion of ACL ruptures are related to impact injury to the side of the knee, a fair amount occur as a result of faulty knee/hip mechanics with running, jumping, landing, or sudden changes in direction.
Research findings have shown a strong positive correlation between weakness in deep gluteal muscles and injury to the ACL and meniscus. Over the course of time, this hypofunction of the hip corresponds with long-term degenerative changes to knee and eventual pain or injury. These tend to manifest earlier in active populations, and 10-15 years later in non-athletes from basic daily mobility.
Rehabilitative strategies after ACL reconstruction often identify and address hip strength deficits and provocative biomechanics in order to decrease risk of ACL rupture after surgical repair.
Similarly, meniscus injury can be related to acute trauma or as a result of chronic, repetitive mechanical dysfunction of the knee. What is most typical is repeated 'valgus' at the knee, an inward collapse of the knee beyond a position of stability, creating excessive torsional forces between the femur and tibia.
Over a long enough time frame, some may even notice their knees now touch when they stand with feet close together, often referred to colloquially as being 'knock-kneed.' These changes in bony alignment further disadvantage the gluteal muscles from functioning properly. The ramifications move down the kinetic chain, excessively loading the arches of the feet and the big toes.
Middle Adulthood: Low Back Pain and Hip Bursitis
As Americans enter middle adulthood, more have issues with low back pain as well as hip pain, sometimes referred to as trochanteric pain. There are many, many different versions of back pain and hip pain, but a few that directly relate to decreased function of the deep hip stabilizers.
Several contributing factors can be cited, but most common are a decline in physical activity, as well as hormonal changes that occur with women as they begin the menopause process. At this stage in life, someone who has had weakness in the gluteals for 10-15 years, now has a decade of poor control of the pelvis and lower back during daily walking and standing.
In this age group, hip bursitis occurs much more frequently and is almost twice as prevalent among women. According to one study, a majority of hip bursitis may be resultant of mild tendon or muscle tears in the gluteus medius. Primary care physicians may be apt to treat the inflammatory pain quickly with medications, but are often unaware any precipitating muscle/tendon pathology.
Similarly with young adult athletes, mild muscle tears and tendinoses are frequently the result of muscle insufficiency, overuse, or a sudden increase in activity. Regardless, concerted rehab is essential to long term recovery. As weak gluteal muscles are less able to do their job, the back muscles will often try to 'pick up the slack.' Unfortunately they are not well suited for the job, and can become aggravated in the process, generating back pain as a result.
Lastly, overuse of weak gluteus medius and gluteus minimus may result only in isolated muscle pain or myofascial pain. The gluteus medius, when aggravated, can refer pain that is often misinterpreted as lumbar spine pain. It may also be confused with sacroiliac (SI) joint pain. Gluteus minimus referral pain runs along the outside of the leg, and due to a propensity to run as low as the ankle at times, is often misdiagnosed as sciatica.
Retirement Age and Beyond: Back Surgery and Total Joint Replacement
Joint replacement used to be associated with older adults in their 60s and 70s, but in the last 10 years has grown in prominence with Americans in their 50s. This is likely for good reason, as research has shown that if patients wait too long to have this surgery (10-15 years of pain and dysfunction), return to full function is much less likely.
As you have read above, weakness and/or dysfunction of the gluteals changes the mechanical stability of the knee and hip joints in a big way. Imagine a door hinge that's missing 2 of 3 screws, or better yet, a door that was missing the top or bottom hinge. The mechanical load on other structures nearby increases exponentially, in ways never intended anatomically.
As one might expect, restoration of normalized function in the deep hip stabilizers is critical for optimal outcomes after both knee and hip replacement. In younger, active patients this is easiest. Without surprise, many older patients show signs reflective of 10-30 years of hip dysfunction. It's difficult to restore muscles in 8-12 weeks that have not worked correctly for decades.
Often before an arthritic hip is identified as the source of pain or dysfunction, patients may be referred to PT for the complaint of low back pain. As hip function declines with age, whether from disuse, weakness, or progressive disease, overall mobility of the joint is often lost. As rotation is lost in the hip, it is absorbed by the lumbar spine, a relationship well studied in golfers.
As flexion and extension range of motion of the hip are lost, the lumbar spine becomes more mobile to compensate. Simple tasks like sitting and standing tall may start to become painful and associated with disc problems or spinal stenosis.
Some older Americans will develop spinal stenosis, a condition wherein the spine compresses neural or vascular tissue during upright postures. In these people, a loss of mobility in the hip is shown to worsen symptoms and function drastically. A lack of mobility and strength in the hips will make recovery after a back surgery much more difficult. Many of these patients report a history of knee injuries or surgeries from many years before, that again paints a picture of chronic dysfunction of the hips.
I hope after reading the above, it is easier to understand, even to a small degree, the relationship between hip function and so many common injuries. Strong, healthy, and mobile hips are found to benefit everyone across many walks of life. Suboptimal hip health can interfere with high school sports, decades of recreational running, the ability to spend time on your feet each day for work, the ability to squat or kneel for gardening, and the ability to retrieve a golf ball.
Hip wellness is critical throughout the lifespan. Consistent pain with function, even at a low level should be addressed early and not put on the back burner. If you wait until you are no longer able to put on your own socks and shoes, it may be too late for a conservative approach to provide much benefit.
Don't wait for a recommendation from your primary care physician, as it's not their specialty. Don't wait for coverage from your insurance provider. The unfortunate side of our current healthcare system is that it is often more reactionary than it is preventative. Take care of your body for the long term, because it's the only one you have!
Until next time, don't stop moving!