An overview of the conditions affecting the Hip, each with information on how they develop, on diagnosis and on treatment. These texts do not replace a medical consultation — in the case of symptoms, we will determine the individually appropriate treatment together.
Coxarthrosis is defined as osteoarthritis of the hip joint. Osteoarthritis of the hip describes degenerative changes in the joint cartilage and in the surrounding bone, which clinically are initially accompanied by load-dependent pain. As the disease — that is, the wear — progresses, restricted movement and pain at rest increasingly occur as well. Pain can also arise through a so-called “activation” of the osteoarthritis, for example through a fall (trauma) or spontaneously. In these cases we speak of an activated osteoarthritis, which is usually accompanied by swelling, warmth and an increase in pain. The incidence of wear is steadily increasing overall. This is primarily attributable to the constantly rising life expectancy, coupled with an ever-higher demand for quality of life.
The hip is a ball-and-socket joint and is one of the largest joints in the human body. It is composed of the femoral head and the acetabulum (socket). In a healthy hip joint, the femoral head and socket are covered with a layer of cartilage that allows the joint components to glide and cushions the forces acting on the joint. The cartilage itself has no supplying blood vessels, which is why it depends on movement — in the form of constantly alternating loading and unloading — as well as on the synovial fluid.
In principle, two types of hip osteoarthritis are distinguished: primary (idiopathic) and secondary coxarthrosis. Primary coxarthrosis usually begins without a known cause after the age of 60. The causes of secondary coxarthrosis can be malalignments of the hip joint (hip dysplasia), rheumatic and bacterial inflammation, and the late consequences of injuries (post-traumatic). Another significant cause of secondary coxarthrosis is so-called femoroacetabular impingement. In addition, being overweight, overuse (among other things through extreme sport) and other metabolic or neurological diseases can also lead to signs of wear.
Diagnosis
At the beginning of the wear there are initially load-dependent complaints in the groin and on the outer thigh, occasionally also in the area of the buttocks. As the disease progresses, restricted movement and pain at rest increasingly occur. Patients usually complain of discomfort when walking, climbing stairs or putting on shoes and socks. In the advanced stage this leads to a marked painful limp.
On clinical examination by the physician, tenderness on pressure in the groin is found. Even in the early stage, inward rotation, abduction (spreading) of the hip and over-extension of the leg are characteristically restricted, in the sense of a so-called capsular pattern. In the end stage of coxarthrosis, the mobility of the hip is maximally restricted in all directions.
A standing pelvic overview image and an X-ray of the affected hip in two planes are in most cases sufficient for a diagnosis. In the early stage, magnetic resonance imaging (MRI) should also be considered, in order to rule out femoroacetabular impingement, labral pathologies or necrosis of the femoral head. On the X-ray image, hip osteoarthritis shows a narrowing of the joint space, bony attachments (osteophytes), so-called cysts in the acetabular roof and in the femoral head, and subchondral sclerosis.
Treatment
Particularly in early stages, conservative therapy should always be applied first. This includes weight reduction in the case of being overweight, medication and physical therapy, and moderate physical exercise (hip-sparing activities such as swimming, cycling and walking). Sports such as tennis, squash and other ball sports with increased jumping strain, as well as abrupt changes of direction in the sense of “stop and go” sports, should rather be avoided.
The overriding aim of the therapy should be the preservation of the musculature and of mobility. For drug therapy, oral painkillers (NSAIDs) and local pain infiltrations with cortisone, injected into the hip joint, are available. In addition, dietary supplements and infiltrations with hyaluronic acid or autologous conditioned plasma (ACP) can be considered, although there is no clear scientific evidence for these.
Only if these conservative methods do not lead to the desired success is a surgical procedure — usually endoprosthetic joint replacement — necessary. In cases of labral pathologies and femoroacetabular impingement, a hip arthroscopy can also be performed in younger years. In cases of advanced disease, the total endoprosthesis represents the gold standard of treatment. In recent years, minimally invasive procedures for joint replacement have become increasingly established, whereby the term “minimally invasive” refers to the sparing of the musculature rather than to the length of the incision. I personally prefer the minimally invasive anterolateral approach with a prosthesis whose load-bearing capacity and stability have been known for decades.
This syndrome is one of the nerve compression syndromes and describes a compression or narrowing of the purely sensory skin nerve on the outer side of the thigh (the lateral femoral cutaneous nerve, a branch of the lumbar plexus). Those affected suffer in part from burning pain or abnormal sensations, up to numbness, on the front and side of the thigh. Men are affected about three times more often. The condition can be promoted by metabolic diseases such as diabetes. Prolonged standing with the hip joint over-extended in particular can lead to a stretching of the nerve and thereby to a worsening of the clinical symptoms.
Relief, by contrast, usually occurs when sitting. The complaints are frequently caused by mechanical irritation such as clothing that is too tight, for example overly tight jeans or belts. Both being overweight and being underweight can act as a trigger or contributing factor.
Treatment
Treatment is initially always conservative. Clothing that is too tight should be avoided in any case. In the case of being overweight, weight reduction is advisable. Occasionally, a diagnostic and therapeutic infiltration of the nerve — either blind or ultrasound-guided — can provide relief. Surgery and exposure of the sensory nerve is necessary only in cases that are refractory to therapy.
Condition 03
Piriformis Syndrome
Definition
The piriformis muscle lies beneath the gluteal muscles, between the sacrum and the thigh, and is one of the muscles of the hip. It represents the anatomical guiding structure of the sacral plexus. The muscle is prone to painful tension or shortening and then leads to pain that usually radiates into the buttocks or the back of the thigh.
These pains are frequently confused with radiating back pain (lumbar radiculopathy) or sciatic pain, which is why the term pseudo-sciatica is also used. Possible causes of the complaints are prolonged sitting — especially when the pelvis is tilted to one side, as can be the case with a wallet in the back pocket. Lifting objects incorrectly, as well as the changed radii in skiing (carving skis), have recently given this syndrome a new prominence.
Diagnosis
Painful hip irritation, as well as pain when spreading the leg sideways (abduction) and rotating it outwards (external rotation) against resistance, together with tenderness of the muscle on pressure, are clear indications of piriformis syndrome. In manual medicine, particularly in the fascial distortion model (FDM), a so-called herniated trigger point in the area of the buttocks is frequently discussed.
Treatment
Injection of painkillers (local anaesthetic) with a small dose of cortisone can provide relief. In addition, physiotherapy helps — above all stretching of the piriformis muscle, eccentric loading and isometric exercises. In my view and in my hands, trigger point treatment has also proven to be a very effective therapy.
Condition 04
Psoas Syndrome / Psoas Irritation
Definition
Psoas irritation, or iliopsoas syndrome, describes an irritation of the iliopsoas muscle, which runs from the lumbar spine over the groin at the front edge of the hip joint and inserts on the lesser trochanter of the thigh bone. In the area of the hip joint, between the pectineus and iliopsoas muscles, lies a bursa, the so-called iliopectineal bursa, whose task is to minimise friction between the two muscles and the bone. In the case of irritation, inflammation of the bursa frequently occurs, characterised by the formation of effusion. The syndrome — or the irritation — is induced either by overuse or by incorrect loading. Such irritation is also repeatedly found after the implantation of an artificial hip joint, which can sometimes be explained by the altered biomechanics or by mechanical irritation from the socket.
Diagnosis
In the initial phase, pain when bending the hip joint against resistance is the main feature. Over-extension of the hip is also painful. In the advanced stage, or with marked effusion, a protective flexed posture of the hip joint can develop. As differential diagnoses, problems of the sacroiliac joint, a disc herniation of the lumbar spine and diseases of the bowel or kidney must be ruled out.
Treatment
As with almost all overuse or irritation of muscles, the treatment depends on the severity of the symptoms. In the acute phase, modification of strain and pain relief are the priority. This can be done in part with the use of anti-inflammatory medication or the infiltration of a local anaesthetic, with or without a glucocorticoid (cortisone). Following the sports-medicine treatment of muscle fibre tears, the treatment proceeds according to the so-called RICE rule (rest, ice, compression and elevation).
As recovery progresses, targeted physiotherapy — for both treatment and prevention — should be aimed for. Here, targeted muscle strengthening in combination with eccentric loading is the priority. Manual techniques, as used in osteopathy, manual medicine and the fascial distortion model (FDM), can also be very helpful. Particularly worth highlighting here are so-called strain-counterstrain (Jones techniques), post-isometric relaxation (Mitchell techniques) and trigger band or trigger point treatments.
