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Gluteal Tendinopathy – By Nicholas Musso

What is Gluteal Tendinopathy? 

The gluteal tendons are the fibres that connect the gluteal muscles to your hip. Gluteal tendinopathy is an injury or pathology of these tendons, most commonly it is a result of repeatedly overloading the tendon. While pain may come on suddenly, tendinopathies actually develop over a period of time, and pain will most often come at a later point. Because of this, tendinopathies are considered to be overuse injuries rather than acute injuries and are usually managed differently. For further general information on tendons and tendinopathy please refer to the “What is a tendon and tendinopathy” blog.

What are the symptoms?

Gluteal tendinopathy usually causes pain and tenderness on the outside of the hip, as well as loss of full movement and reduction in strength in the hip muscles. Pain can be local to the hip or spread further down the outside of the leg.

You may also get pain during certain activities which place more load on the tendon, these include:

  • Climbing stairs
  • Standing on one leg
  • Crossing your legs
  • Standing up from a chair
  • Lying on your side (particularly at night time)

Your pain may also increase with more demanding tasks such as jumping and hopping. Your physiotherapist will also be vigilant for determining there may be other causes for your hip pain.

What are the risk factors?

Gluteal Tendinopathy is primarily seen in post-menopausal women, with some researchers suggesting that 25% of women after the age of 55 will experience it at some point due to changes in anatomy and bioechanics. However, anyone can develop gluteal tendinopathy, it is not an age or gender-specific injury.

If you have had a previous injury (e.g. to the knee or ankle), the muscles surrounding those areas may not be working optimally even though the injury itself has healed. This can lead to increased stress being placed on physical structures further up or down the body (such as the gluteal tendon) which is overloaded and gradually increases in symptoms.

It is not uncommon to see people present with Gluteal Tendinopathy following a large increase in the amount of exercise being completed without being prepared for the increase in load i.e. mid-way through a sporting preseason, or in late January with a New-Years resolution spike in exercise. Runners who train on hills are particularly at risk.

How is it diagnosed?

A physiotherapist will be able to complete a comprehensive assessment of your problem area including taking a detailed history, previous medical and injury history, as well as a full physical assessment to determine the diagnosis and true cause of your problem.

It is unlikely that you will require a scan, as researchers have found that there is a poor link between findings on scans and pain symptoms. However, in rarer cases, your doctor or therapist may request an ultrasound or MRI scan if they suspect that your problem will require longer-term management.

What are my treatment options?

Physiotherapy will include a variety of treatment options, however the most important treatment is exercise therapy. This may seem counterintuitive as it is excessive loading that caused these symptoms, however load is also the answer! More specifically, it is putting the right amount of load through the tendon and gradually increasing the capacity of the tendon that is essential for promoting proper repair. While this is the primary treatment for promoting long-lasting improvement, physiotherapy treatment will also be focused on relieving the painful symptoms. There are a variety of techniques that may be suitable for you, including:

  • Icing
  • Medical management as prescribed your GP or pharmacist
  • Shockwave therapy
  • Rest from activity if required
  • Modification of current activity (i.e. load management)
  • Managing lifestyle factors that may be contributing to your pain such as climbing stairs,
  • Stretches (stretches may not always be useful and may sometimes increase your pain, these will be prescribed as the therapist deems suitable)

Book an appointment today for your assessment!

Blog by Nicholas Musso (Physiotherapist)

Groin Pain – Blog by Kara Giannone

The story of Osteitis Pubis…

Osteitis Pubis (OP) was a very fashionable diagnosis in Australia for a very long time. It seemed every footballer with chronic groin pain was diagnosed with OP. You may be reading this thinking “I had OP, it must exist!”. However in fact, the labelling of OP was far from correct. As many of you will know, the term “itis” refers to inflammation and therefore Osteitis Pubis is suggesting that this is an inflammatory condition of the pubic bone. However, studies involving biopsies of patients diagnosed with OP have in fact revealed no inflammatory markers present. In fact, what we now know is that rather than inflammation, there is a stress response occurring in the pubic bone, similar to that which one may get in a stress reaction or stress fracture.

A funny story came out of the AFL recently, where an Adelaide Crows Footballer was seen reporting to media that he had OP. Meanwhile, coaches were reporting to the media that this player had pubic related groin pain – both parties talking about exactly the same injury, however using different terminology. Quite hilariously, the media went into a frenzy spinning a story that there was conflict within the Adelaide Crows as players and coaches were not in agreement. Maybe the media reporting this story should read this blog hey!

So I’m sure you’re thinking…“I’ve got pain in my groin and if it’s not OP, what is it then?”

Well, turns out pubic joint pain is only one small piece in a large puzzle that can lead to groin pain.

In 2014, the medical experts came together in Doha and decided on universal terminology. They concluded that groin pain should be classified as one or a combination of the following:

  1. Adductor-related groin pain
  2. Pubic-related groin pain
  3. Iliopsoas-related groin pain
  4. Inguinal-related groin pain (which includes abdominal related groin pain)
  5. Hip-related groin pain

 

So, what does this all mean?

The groin is a very complex region of anatomy as shown in the image above. As a result, pain in the groin can be referred from multiple structures. Thanks to the Doha agreement outlined above, we have universal understanding that groin pain can be referred from a wide range of structures including muscles such as the adductors, hip flexors (Iliopsoas) or abdominals and from joints including the hip joint and pubic bone joint.

So what should you do?

If you are suffering from groin pain, it is integral to determine what structure is causing this pain as this will guide treatment. Our physiotherapists are trained in assessment of a wide range of musculoskeletal conditions including groin pain. During this consultation, our physiotherapists will assess:

  • Posture
  • Gait
  • Biomechanics
  • Tenderness via palpation
  • Strength, endurance, power and flexibility – particularly of abdominals, adductors and Iliopsoas
  • Joint integrity – particularly of the hip joint and pubic bone joint

Following this assessment, our physiotherapists will ascertain the cause of your groin pain and treat you accordingly.

What will treatment involve?

It is paramount that any muscle deficits in terms of strength, power, endurance and flexibility are addressed. Therefore, a graduated exercise based rehabilitation program must be at the core of intervention. In addition, treatment of groin pain may include, but is not limited to:

  • Education regarding pain management and load management strategies
  • Soft tissue mobilisation
  • Taping
  • Dry needling
  • Sport (or activity) specific training

So if you’re experiencing groin pain make an appointment below at one of our clinics at Total Physiocare Heidelberg, Reservoir, Camberwell and Footscray

Book an appointment today for your assessment!

 

Snapping Hip Syndrome (Dancer’s Hip) – Blog by Alice Smith

What is it?

Snapping hip syndrome (SHS) is a condition that is defined by a snapping or popping sensation in or around the hip when it is moved in a certain direction. It is most commonly felt when walking, getting up from a chair and swinging your leg around. The sensation occurs when a muscle or tendon moves over a bony protrusion in your hip. There are various causes of SHS and there a thorough examination is required. Some people do not experience pain or dysfunction with the sensation, whereas others report pain and weakness which interferes with their hobbies. In some cases, snapping hip leads to a painful swelling of the fluid- filled sacs that cushion the hip called bursitis.

Snapping hip is believed to affect 5% of the population and is most commonly found in females between the ages of 15 to 40 years old. Sports which involve repetitive hip movement forwards and backwards can lead to this condition. This overuse injury is most commonly seen in dancers, soccer players, runners and gymnasts.

Causes:

The “snap” sensation experienced may be a result of the iliotibial band snapping over a structure on the outside of your hip called the greater trochanter. Some patients describe the sensation of the hip popping in and out of the socket or dislocating. This is however, not what is occurring. The symptoms develop gradually and without a traumatic incident.

Alternatively it can be caused by the iliopsoas tendon snapping over a bony area of the pelvis. This is a muscle located predominantly at the front of pelvis. Patients describe a deep “clunk” or “click” that can be illicit by extending the hip or rotating it out to the side.

Least commonly, it can be the result of a cartlidge tear or loose body in the hip which also leads to the hip “locking up”. This cause of SHS is normally a result of an injury or traumatic event to the hip.

Examination:

During your assessment, your physiotherapist will obtain a detailed history from you about your hip symptoms to rule out any other conditions. You physiotherapist will then perform specific tests on your hip to determine the exact location and cause of the snapping hip sensation. For example, often in dancer’s a deep plie can illicit the hip snap sensation, and therefore they will be asked to perform this movement during the assessment. Ultrasound or MRI can be advised if your physiotherapist is concerned about internal hip pathology.

Management:

The first line of treatment for this condition involves reducing pain with rest, ice, non-steroidal anti-inflammatories if required and physiotherapy. Once your pain has settled, physiotherapy management then aims to address specific impairments such as a tight hip flexor muscle in order to fix imbalances which may have led to this condition. In this cause management will include stretching of the front of your hip to lengthen the muscle combined with strengthening exercises and pelvic stabilisation exercises. You will also be educated to avoid the positions and movements which cause your symptoms and aggravate your pain.

If you are experiencing snapping hip syndrome, please contact us so we can help you out with a comprehensive assessment and treatment plan.

Book an appointment today for your assessment!

Blog by Alice Smith (Physiotherapist)

Total Hip Joint Replacement (THJR)

What is a Total Hip Joint Replacement? – Blog By Christian Bonello

A Total Hip Replacement (THJR) is one of the most common operations in orthopaedic surgery.  It is a surgical procedure whereby the diseased hip joint is replaced with an artificial prosthesis. As the hip is classified as a ball-and-socket joint; the ‘socket’ is formed by the acetabulum, which is part of the pelvis bone, and the ‘ball’ is the head of the femur or thigh bone. The bone surfaces of the ball and socket are covered with articular cartilage which cushions the joint and enables smooth movement. Overtime the joint may become degenerated causing reduced movement and increased pain especially in activities such as walking.

A THR is therefore performed to relieve pain of degenerative diseases affecting the hip joint. The procedure is performed by replacing the diseased head of the femoral (thigh) bone with a metal stem that is placed into the hollow center of the femur. The femoral stem may be either cemented or “press fit” into the bone. A metal or ceramic ball is then placed on the upper part of the stem and this ball replaces the damaged femoral head that was removed. The damaged cartilage surface of the socket (acetabulum) is removed and replaced with a metal socket. Screws or cement are sometimes used to hold the socket in place. A plastic, ceramic, or metal spacer is then inserted between the new ball and the socket to allow for a smooth gliding surface.

Type of Incisions

Depending on the patients age, fitness level, hip presentation and the orthopaedic surgeon’s preference; two incisions are commonly utilised for patients undergoing a Total Hip Replacement:

  • Posterolateral approach: Incision is made via the rear and side of the hip joint. Due to the muscles that are separated, limitations of hip movement are advised in the first six weeks following surgery. These include keeping the height of the knee below that of the hip, no twisting the lower limb inwards and no bringing the leg past the middle of the body. Special equipment such as an over-the-toilet chair, higher chair and a pick-up stick are usually recommended during the first six weeks following surgery.
  • Anterior approach: the incision is made through the front of the thigh and offers a potential for an accelerated recovery time as key muscles are not detached during the operation.

Who requires a hip replacement?

A total hip replacement is considered for patients whose hip joints have been severely damaged by either progressive arthritis, trauma or other joint pathology.

  • The most common type of arthritis occurs where there is gradual loss of articular cartilage causing bone remodelling, joint inflammation and loss of normal joint function. It mainly affects people over the age of 50 and usually affects people with family history of osteoarthritis and may cause significant pain.
  • Rheumatoid Arthritis: This autoimmune condition involves chemical changes in the synovial membrane surrounding the joint (within the capsule), causing it to become thick and inflamed. This causes the breakdown of the cartilage and joint degeneration over-time.
  • Post-Traumatic Arthritis: Trauma to the hip joint either via serious hip injury or fracture can cause the bone and the cartilage to not heal correctly. This can mean that the hip joint may develop arthritis. Alternatively a THR may be the intervention of choice for orthopaedic surgeons managing a hip fracture in older populations.
  • Avascular necrosis:An injury to the hip, such as a dislocation or fracture, may limit the blood supply to the femoral head.  The lack of blood may cause cell death to the bone tissue resulting in tiny bone breaks and the bones eventual collapse. Some diseases can also cause avascular necrosis.
  • Childhood hip diseases: Some infants and children are born with hip pathology. Even though many of these conditions are successfully treated during childhood, they may cause arthritis later on in life if the hip joint does not grow in optimal alignment and the joint surfaces are affected.

How can I prepare for Surgery?

  • Commence exercising

It is recommended prior to your surgery that you attend a physiotherapy class where you will be taught a series of exercises that will help to strengthen the muscles in your legs. To physically prepare for the surgery you will be given a home exercise program designed by a physiotherapist or exercise physiologist. This will focus on increasing the strength of the muscles in your legs, your abdominal muscles and your arms. This improved strength will help you to mobilise more easily following your surgery. The physiotherapy information will also help you to know what will be expected of you after your surgery.

  • Reduce alcohol intake

It is always recommended that you decrease your alcohol intake prior to surgery. Some of the drugs given to you either during or after your operation can interact with any alcohol that is in your system.

  • Lose Weight (for patients who are overweight)

By losing weight prior to your surgery, it will help reduce the stress on your new hip joint and help you mobilise more freely. Being over-weight can increase your risks of a raised blood pressure and therefore complicate your post-operative period.

  • Stop Smoking

Cigarette smoking has been proven to increase the time it takes you and your joint to heal. It’s a good idea to stop smoking at any stage, but this is a perfect opportunity.

Rehabilitation

Rehabilitation exercises following a Total Hip Replacement will start on the evening of or the day following your procedure depending on the surgeon’s protocol. This will be guided by your physiotherapist and will include hip range of motion exercises, muscle activation and strengthening exercises and early mobilisation. Following a Total Hip Replacement, you can usually put as much weight on the knee as you feel comfortable, however this will be guided by your surgeon.

If a rehabilitation hospital is not required, it is recommended to start outpatient (private) physiotherapy a week following discharge from hospital and arriving home. This will incorporate manual therapy and progression of exercises to optimise the outcome of surgery. If required, hydrotherapy may also be of benefit during this period.

It is essential during this time to manage both the normal post-operative responses – such and swelling, joint stiffness, bleeding and muscular tension – at the same time as you push to improve muscular strength and joint range of motion. Finding the right balance with the aid of your physiotherapist will ensure an optimal post-operative outcome.

 

Expected recovery

It may take up to 12 months to experience a full recovery from THJR surgery. Our team expect that you graduate from 1:1 physiotherapy into a self-managed exercise routine or group class during your rehabilitation. It is vital to maintain half an hour of daily exercise throughout your life and return to activities that are important to you. Ideally such exercises should incorporate a mix of aerobic exercise that elevate your heart rate and strength-based training.

At Total Physiocare we are responsible for the orthopaedic care of patients at both Warringal Private and Western Private Hospital. We also offer pre-habilitation exercise programs with our team of physiotherapists or exercise physiologist and hydrotherapy services to assist in the recovery plan following a Total Hip Replacement. 

Book an appointment today for your assessment!

Post by Christian Bonello (Physiotherapist)