Lateral Hip Pain

Lateral Hip Pain

This month’s newsletter will be focusing on lateral hip pain, which is often referred to as trochanteric bursitis. Recent evidence suggests that the primary cause of pain may actually be a result of gluteal tendinopathy, rather than from inflammation of the bursa, which may actually be a secondary finding to tendinopathy*. Tendinopathy involves changes to the structure of the tendon and breakdown of the collagen structure of the tendon, resulting in a tendon that is more like a weak spring as opposed to a healthy tendon that behaves like a stiff spring. Traditionally tendon overload has been considered to be tensile; however compressive load may play a significant role in the development of tendinopathy**. The gluteal muscle group is made up three muscles – gluteus maximus, medius and minimus, all of which are located in your hip region. The smaller two, gluteus medius and gluteus minimus, are the muscles that are commonly involved in gluteal tendinopathy.
Gluteal tendinopathy most commonly occurs over the age of 40, and is more common in woman than men. Common complaints from someone with gluteal tendinopathy include pain with the following activities: lying on the effected side, walking, standing, ascending/descending stairs and sitting. Pain is typically located on the outside of the bony part of the hip, which is the attachment point of the gluteal muscles. Similar to other tendon issues, this condition usually develops as a result of tensile overload to the tendon, excessive tendon compression at the point of insertion (attachment to the bone), or most likely a combination of both. Impaired tendon loading may be from long-term over-use or under-use of the tendon. Significant compression of the gluteal tendon occurs when the hip is in a position of adduction – where the thigh moves toward the midline of your body.
Clinically, altered functional movement patterns of the lower limbs are commonly observed in those who have gluteal tendinopathy – typically increased hip adduction during weight bearing (for example knees dropping in when standing on one leg or squatting). This is likely due to weakness of the gluteus minimus and medius muscles, whose job is to rotate the thigh and to lift the leg out to the side. They also play a significant role in controlling the pelvis while walking. If these muscles are not working efficiently, increased load may be placed on surrounding structures, particularly the iliotibial band (ITB). This is especially true if the hip is in a position of excessive adduction. Higher load on the ITB results in more compression on the attachment site of the gluteal tendons, which further contributes to tendon pathology.
Lateral Hip Pain
Current guidelines on the best way to manage gluteal tendinopathy include similar concepts to managing tendon pain in other areas of the body. Limiting the amount of compression at the site of tendon attachment is important, and can be achieved by altering postures and/or movements to decrease the amount of hip adduction. This may include changing from sleeping on your side to sleeping on your back, avoiding crossing your legs in sitting, and functional movement retraining to improve pelvic control during weight bearing tasks. Isometric (static) muscle contractions may be used early on as a way to reduce tendon pain. Specific gluteal muscle strengthening is important, as tendons require appropriate, gradual loading to become stronger and more resilient. These strengthening exercises should be gradually progressed in terms of load and in varying functional, weight-bearing positions specific to you. Passive treatments such as massage may also be useful in helping to restore muscle length without causing tendon compression, which can occur with stretching.  Your Physiotherapist will let you know if this is an appropriate treatment option for you.
*Grimadli, A; Fearon, A. Gluteal tendinoapty: Integrating pathomechanics and clinical features in its management. Journal of Orthopaedic and Sports Physical Therapy, 2016

**Cook, J; Purdham, C. Is compressive load a factor in the development or tendinopathy? British Journal of Sports Medicine, 2012

Author

Jezamine Johnson
Physiotherapist
Pilates Instructor

Jezamine has a keen interest in managing chronic conditions, particularly low back pain, and non-musculoskeletal conditions such as COPD. She also enjoys assisting in rehabilitation of sports people following an injury. In addition to treating at the clinic, Jezamine also runs the Thursday afternoon Hydrotherapy sessions at Bayswater Waves, as well as Clinical Pilates classes twice per week on Monday and Wednesday afternoons.

Location

1/89 Old Perth Road Bassendean 

Contact

(08) 9279 7411

Email

Opening Hours

Monday-Friday 7am-7pm
Saturday 8am-12pm

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Breathing

Low Back Pain (LBP) and Cognitive Functional Therapy (CFT)

WHAT IS COGNITIVE FUNCTIONAL THERAPY (CFT)?

CFT provides a patient centered targeted approach to management of LBP based on a thorough examination.  This classification based management approach for LBP considers many domains including: lower back movement and postures, psychological factors, social factors, workplace factors, comorbidities (e.g. diabetes, obesity), pain processing mechanisms: influenced by genetics and life experiences, sleep and lifestyle factors and their relative contributions to an individual’s LBP. CFT challenges thoughts and behaviours in a functionally specific and graduated manner. 

It differs from Cognitive Behavioural Therapy (CBT) as changes in beliefs, thoughts and emotions can be realized by the patient when they experience an improvement in symptoms as they move which may challenge previous beliefs, experiences and knowledge about their condition.  In a recent study CFT when compared with a manual therapy and exercise group showed clinically and statistically significant large effect sizes across multiple dimensions. The group receiving CFT was 3x less likely to take time off work in the 12 months following treatment1.

As physiotherapists, in a practical sense, it means we are considering both mechanical and non-mechanical aspects of a person’s disorder. By managing patients in this way we are helping them better understand their pain and to move and function in a way that does not perpetuate their pain.  By involving the patients in the problem solving and goal setting the longer term prognosis is improved.  Essentially this puts patients back in the “driving seat” for directing the course of their rehabilitation and Sarah and I are both excited about the results we are seeing implementing our improved skills so far….

Breath

Low back pain (LBP) is very common and is currently the leading cause of disability worldwide3. Only a very small proportion of people with LBP have serious pathology, such as vertebral fracture, cancer, infection or underlying inflammatory disorder, causing their pain2. Unfortunately using a scan to help diagnose LBP is not reliable because MRI abnormalities are as common in those with LBP as in those without. A common recommendation across all high quality LBP guidelines is routine imaging is discouraged unless serious pathology or specific disease is suspected e.g. if surgery is being considered or there has been a limited response to conservative care. There is no evidence that routine imaging improves LBP outcomes. Over time there has been a significant increase in LBP expenditure without any change in associated levels of disability.

 

Key positive messages supported by current best evidence regarding LBP include:

  • The causes of LBP are rarely serious
  • LBP has a good prognosis
  • Stay active and resume normal activity as soon as reasonable
  • Bed rest is specifically not advised
  • The back is a strong structure
  • Pain does not equal harm
Symptoms

Key management principles for LBP include:

  • Diagnosing LBP via thorough questioning and physical examination
  • Limited use of imaging
  • Advice about what’s contributing to LBP and an understanding of what’s contributing to the pain experience
  • Strategies to self-manage pain including physical activity
  • Treatment and exercise specific to the problem
  • Medication when required but not as the primary management


The key message here is the clear majority of people with LBP, including leg pain (sciatica), will have a good outcome with evidence based, non-surgical care.   Cognitive Functional Therapy is an emerging approach to deliver high quality care considering the complexity of factors that can be relevant to a patient’s lower back condition.  At Central Bassendean Physiotherapy we pride ourselves on our accurate diagnosis and evidence based, contemporary management of LBP. We are happy to have a further discussion on the material presented here.

 

You can BOOK HERE or Call us to make an appointment at 9279 7411

 

  1. Vibe Fersum, K, O’Sullivan P, Skouen J, et al. Efficacy of classification based cognitive functional therapy in patients with non-specific chronic low back pain- A randomised control trial. Eur J Pain 2013;17;916-28
  2. Almeda M, Saragiotto B, Richards B, et al. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018;208(6):272-275.
  3. Clark S, Horton R. Low back pain: a major global challenge. The Lancet 2018;391(10137):2302.

 

Location

1/89 Old Perth Road
Bassendean

Contact

(08) 9279 7411

mail@centralbassendeanphysiotherapy.com.au

Opening Hours

Monday-Friday 7am-7pm

Saturday 8am-12pm

Social Media