Mobility for normal daily functions depends largely on the health and integrity of the hips. As the mechanical hub for the lower extremities, the ball-and-socket joint of the hip is very stable. It is injured less often than the shoulder, knee and ankle.1 In fact, most hip problems develop secondary to biomechanical dysfunctions, which can still be very disabling.
Causes of Hip Problems
Common hip conditions and their causes usually indicate underlying biomechanical imbalance2 or overuse syndrome. Trochanteric bursitis, inflammation of the bursal sac between the greater trochanter and the tendons that pass over it, occurs in runners or athletes in running-oriented sports such as soccer or football.3 Recurrent muscle strains of the hamstrings that extend the hip joint and adductors – groin muscles that pull the legs together – are common in sprinting and pivoting sports that require sudden accelerations and change of direction.3
When the piriformis muscle tendon irritates the sciatic nerve, which supplies the lower extremities with motor and sensory function, piriformis syndrome results.3 The irritation may increase with overuse and is potentially aggravated by pelvic unleveling as a result of postural imbalance.2 Snapping hip syndrome occurs when the iliotibial band tendon or the iliopsoas tendon snaps over the greater trochanter with hip flexion and extension,3 and also may be affected by postural imbalance.2
While some hip problems are due to trauma, the vast majority are chronic in nature, especially those seen by chiropractors. Most frequently, hip dysfunction is due to chronic degenerative change (hip joint DJD), such as that usually seen in osteoarthritis of the hip. Osteoarthritis of the hip joint is often an end result following years of improper biomechanics and dysfunction.4
When the hip joint does not function properly, simple daily activities such as walking down stairs, getting to the bathroom, and even turning in bed, are difficult and often painful. This is because the hip forms a vital link in the lower-extremity kinetic chain, transferring ground-reaction forces from the legs to the trunk during gait.
Caring for the Hip
The adjust-support-rehab protocol for chiropractic care ensures that the hip joint is realigned for proper biomechanical function; balance of the spine and pelvis is restored and stabilized; and muscles and tendons that control motion of the hip joint are optimally conditioned.
Depending on the condition, lower-extremity adjusting for the hip will involve applied manipulation techniques based upon specific need. A second phase of successful treatment is the use of individually designed stabilizing orthotics. Since the hip joints are so intimately involved in gait, orthotic support for the feet is often a necessary treatment component in hip-joint dysfunction.
There are three specific effects of orthotics on the hip joints:
1. Pronation control. The most common problem that interferes with effective foot and leg biomechanics is excessive pronation. This condition occurs as a result of several factors, including loss of the medial longitudinal arch, eversion (tilting) of the calcaneus, or excessive dropping of the talus and/or navicular bones. Support for low arches and calcaneal eversion will reduce pronation at the foot and ankle, thereby decreasing the medial rotational stress on the legs and the hip joints.
Excessive pronation is important to the hip joint due to the probability of transferring abnormal stresses up the lower extremity and into the pelvis and spine.5 Athletes often suffer from "overuse injuries" to areas including the hip joints, many of which are due to excessive pronation.6
2. Leg-length symmetry. The combination of arch collapse and medial rotation of the ankle and leg results in a pelvic tilt. This condition is sometimes known as a "functional short leg," since there is no measurable difference in the anatomical structures of the leg. In this case, the underlying cause of leg-length discrepancy is an asymmetry of alignment, which is improved with proper orthotic support.
3. Skeletal shock absorption. Many hip conditions occur from musculoskeletal impact at heel strike or are compounded by this repetitive shockwave that travels through the body during normal activities. The additional strain placed on the tissues of the lower limbs and pelvis during gait can interfere with the healing of sports traumas; and repetitive shock to weight-bearing joints such as the hips has been shown to cause degenerative changes. Yet because it is so commonplace, we often don't consider how much force is being transmitted from the ground to the feet, knees, hips, pelvis and spine with every step.
Studies have found that the use of a viscoelastic polymer to reduce heel-strike shock will significantly decrease both foot and back symptoms, and prevent lower-extremity overuse conditions.7-8 One researcher who used a tibial accelerometer measured the "shock factor" of nine different insoles in four types of shoes.9 He found a significant reduction in impact loading with the use of the viscoelastic insoles. This means we can reduce the effect of the shockwave on our patients by recommending orthotics made with shock-absorbing materials.
As a third step toward optimal treatment, optimal conditioning of the hip requires therapeutic exercise to increase range of motion, strengthen or add flexibility to overly taut muscles and tendons.10 Again, rehabilitation is specific to the condition, symptoms and joint involvement. In general, an effective program will involve the use of low-tech rehabilitation to apply variable resistance exercises to the lower extremities to improve flexion, extension, abduction, adduction, and internal and external rotation.
Smooth, Working Joints
Since biomechanical alignment problems are frequently found in association with chronic hip complaints, patients must be screened for excessive pronation and/or leg-length discrepancies. Failure to recognize these complicating factors will result in patients with recurring hip complaints or symptoms that vary in location due to the effects of the underlying biomechanical stress.
We can help our patients deal with the effects of musculoskeletal shock and prevent many of the muscle and joint degenerative problems improperly labeled "normal aging." Once their lower extremities are properly aligned and supported, their muscles are strengthened and lengthened, and the hip joints work smoothly, our patients will be able to enjoy the benefits of independent mobility well into their elder years.
References
- Geraci MC. Rehabilitation of the Hip, Pelvis, and Thigh. In: Kibler WB, editor. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg, MD: Aspen Publishers, 1998:216.
- Hartley A. Practical Joint Assessment: A Sports Medicine Manual. St. Louis: Mosby YearBook, 1991:571.
- About Hip Bursitis. Available by clicking here.
- Vaux, P. Hip osteoarthritis: a chiropractic approach. Euro J Chiro, 1998;46(1):17-22.
- Kuhn DR, Yochum TR, Cherry AR, Rodgers SS: Immediate changes in the quadriceps femoris angle after insertion of an orthotic device. J Manip Physiol Ther, 2002;25(7):465-470.
- Busseuil C, et al. Rearfoot-forefoot orientation and traumatic risk for runners. Foot & Ankle Intl, 1998;19:32-37.
- Fauno P, Kalund S, Andreasen I, Jorgensen U. Soreness in lower extremities and back is reduced by use of shock absorbing heel inserts. Int J Sports Med, 1993;14:288-290.
- MacLellan GE, Vyvyan B. Management of pain beneath the heel and Achilles tendonitis with visco-elastic heel inserts. Brit J Sports Med, 1981;15:117-121.
- Johnson, GR. The effectiveness of shock-absorbing insoles during normal walking. Prosthet & Orthot Intl, 1988;12:91-95.
- Murphy, SM, Jurisson, ML. Putting exercise to work for your patients with osteoarthritis. J Musculoskel Med, 1998 June:26-34.
