Post 79: Movement Impairment System and hip pain

Post 79: Hip pain
“Hip pain is a common complaint for which people are referred to physical therapy. The prevalence of hip pain in adults over the age of 60 ranges from 9.7% to 19.2%”

Hip pain…think of a pain that is around the groin region that radiates down to the knee (but on the front/inner part of the thigh). Sometimes pain in the buttock could come from the hip, but other areas that could cause buttock pain should be ruled out first. For instance, the SI joint can also cause buttock pain, but if the person is elderly it is probably not the cause. The spine could also cause buttock pain, and in a majority of “pains in the asses” that I see are coming from a spinal referral.

Hip pain is not the most common ailment that I see in the clinic, but it is not rare either. There are a lot of structures surrounding the hip that are innervated (have a nerve source), which means that there are a lot of structures surrounding the hip that could cause pain. I don’t think that our job as therapists is to find the exact tissue that is causing pain (although there are some patients that just need to know), but our job is to classify the symptoms and place the symptoms into a puzzle that makes sense for us. We do this mostly by pattern recognition (at least for therapists that have seen patterns over his/her careers), but we may also have to do this by using the HOAC method (smart way of saying: “give it a shot and see if it works”).

“Abnormal or excessive loading of the hip has recently been recognized as a potential cause of anterior hip pain and subtle hip instability”
I partly agree with this. For those that don’t know me well, I am certified in Mechanical Diagnosis and Therapy, which was proposed by Robin McKenzie in the 1960’s. He proposed a syndrome called the postural syndrome, in which healthy tissue, abnormally loaded, will create pain with the possibility of becoming a dysfunctional tissue over time. In short, I agree with the above statement.

“Femoracetabular impingement is present in 10% to 15% of the population…symptoms are commonly manifested as insidious groin pain.”

I had to look up the three different types of FAI (the long words from above). This means that the ball and socket portion of the hip is not working appropriately. When thinking of a hip, think of a golf ball and tee. The ball is the ball portion at the top of the thigh. When it is round like a ball, it can spin on the tee without falling off. Now imagine that your tee is a little deeper and larger and can encompass the ball. This portion that would encompass the ball is the acetabulum. It is a piece of cartilage that makes the tee deeper so that the ball can sit in without falling off the tee (think dislocated hip if the ball falls off of the tee). So one type of impingement is if the ball is no longer round, but shaped in a different fashion that makes the ball a little bigger on one side. This would cause the ball to pinch on the acetabulum with certain movements (more on this later).

Another type of impingement is when the tee is malformed. This could cause the tee to pinch on the ball, also causing pain.

Either way, groin pain is the chief complaint typically seen in the clinic.

“Combined hip flexion, adduction, and internal rotation movements (FADIR) along with maximal hip flexion most commonly replicates the pain…catching, clicking and feeling of ‘giving way’.”

Picture a little kid doing the “W” sit. This is what the above sentence describes as FADIR. I know…you’re thinking I can’t do that any more…GOOD! That’s not good for you anyway. Now close your eyes and imagine yourself going up stairs. When you go up stairs, do your knees collapse inwards? Don’t answer yet! Imagine yourself slowly sitting down onto a soft couch (you know what I mean…the ones that you sink down into). Did your knees cave in? DON’T ANSWER YET!! Finally, imagine that you are getting up off of the toilet. Do you have to lean far forward or better yet, rock forward and backwards a couple of times in order to get up off of the toilet? Now you can answer. Did you answer yes to any of these? If you don’t know, that’s alright, my imagination sucks also. Go try it. If you have these things happening, YOU HAVE A PROBLEM!

The first step is simply admitting that you have a problem. Unless you admit that you have a problem, you’ll never get to asking for forgiveness from your hips and knees. I thought that the analogy was good.

Anyway, when the knees cave in, this is a poor position for the knee and the hip when in a hip flexed (knee closer to chest) position.

“Hip joint forces are altered by hip joint positions and changes in muscle force contribution”

“I love it when a plan comes together” Hannibal Smith from the A-TEAM.

This describes another of MDT’s syndromes: the derangement syndrome. This is simply a change in the normal resting position of a joint. It may cause muscle inhibition. This a lay term for “shutting down”. On a side note, there has been major debate on Facebook for the terms used to educate society. For instance, in Supple Leopard, Dr. Kelly Starrett describes a muscle as turning off (he means that it is not working to its fullest potential), but some therapists have a hard time with this phrase. This is why I used the phrase “shutting down”. Maybe they won’t have a as hard of a time with this terminology. I don’t know, but if you don’t get the point…please ask.

When a joint’s position is changed then the muscles that act on the joint will change also. Quick example: my dad used to take me out to plant trees in the forest every year. We would tie the tree down using 3 stakes in order to ensure that the tree grew straight. Now imagine if we used the same 3 stakes, but before driving them in, we placed the tree at a 45 degree angle to the ground. (Think leaning tower of Pisa/Pizza). If we pull on the strings in each scenario, there will be a different outcome on the tree. In one, it will be stabilized and in the other it will fall over even further. This is what happens when a joint is altered in its position. When the muscles contract (the strings are pulled), the joints movement will be altered from normal.

“The 2014 clinical practice guideline on nonarthritic hip joint pain recommends interventions such as patient education, manual therapy, therapeutic exercise, and neuromuscular education, but the strength of the evidence for all of the recommended interventions are at the level of expert opinion”
This is important for all of the PT students that may read this blog. We have entered a world with buzzwords such as evidenced based practice/medicine. We are supposed to be using the highest form of evidence or using “best practice” when treating patients. For this ailment, nonarthritic hip pain, the best we got is a bunch of people coming together to give us an opinion. Granted, the people are really smart, but for a profession that is trying to sell itself as “movement specialists”, we should have more than opinions to sell to patients.

“However, Byrd and Jones report that FAI is not necessarily a cause of hip pain; it is simply a morphological variant…”

Wait… You mean to tell me that having a problem on an image, such as an x-ray or MRI does not correlate to having symptoms?! Obviously I jest. An image alone does not indicate a problem for most musculoskeletal problems. The image must be correlated with clinical signs and symptoms. A person without signs and symptoms is healthy, as some problems noted on an image are correlated with age related deformities. Think of this as a wrinkle. For instance, as we age our muscles go from the texture of filet to the texture of beef jerky. Things start wearing down. We are the ultimate machine, but we have yet to figure out how to keep the machine from breaking down.

“While physical therapists can not change the morphology of the hip joint, they can address movement impairments, muscle strength deficits, and certain aspects of joint range of motion to decrease stresses on the anterior hip joint”

I will not make your bones longer or shorter. I will not change the depth of your joint capsule. I will not make you into something that you’re not. But what we can do is address the issues that you have at that point in time, that aren’t structurally unchangeable. Here’s an experiment I want you do: squeeze yourself into the smallest suitcase that you have and I want you to hang out there for 5 hours and then try to get out. It doesn’t feel so good. I didn’t change any of your structures, but I probably created symptoms. Not all symptoms are related to the structural change, and not all structural changes related to symptoms.

“…movement system impairment syndromes described by Shirley Sahrmann,PT, PhD. The movement system impairment approach places less emphasis on identifying the source of the symptoms and more on identifying the pathomechanical cause.”

I’m always reminded of an old research study, I don’t remember the author, when we give you a diagnosis based on pathoanatomy, we (medical professionals) are right 10% of the time. I can’t specifically tell you which structure is causing your symptoms. What I can tell you is you have symptoms when you move. Maybe if we move a different way your symptoms all go away. It’s my job as a therapist to understand the different ways that movements may affect your symptoms.

“27-year old female…left anterior hip pain July 2014 after doing Miri-directional lunges…continued despite pain…after one week discontinued the multi-directional lunge but continued with deadlifts, squats to 90 degrees…sprinting/walking interval training prior to her injury…discontinued in August due to pain. Before July…she was pain-free…did have clicking, snapping and pinching in both hips…main goal was to return to lifting weights while doing squatting and lunging movements without pain.”
The biggest thing to take from the above is that the patient is active. She is not a couch potato.. This patient is the perfect patient to come into the clinic. I love trying to help these patients get back to their active lifestyles. This is the patient that I am going to go over and above in order to return them back to the gym. I AM A MEATHEAD. I see that as a term of endearment.

“…stood with swayback posture and displayed increased hip medial rotation on the left compared to the right… Had increased pronation bilaterally as well as a positive “too many toes” sign… Range of motion of the lumbar spine was normal and pain-free… Adequate hip flexion range of motion during forward bending but the majority of the motion came from the thoracic and lumbar spine… positive Trendelenburg sign bilaterally.”

 Essentially, description is that of a person with poor usage of the hip muscles and a lazy stance. Could indicate some tightness and she stands with the swayback, but it also may mean that she needs better motor control and a better understanding of what appropriate standing posture actually is. Just from the above description, she seems like many of the females that I see in practice.

“During single leg stance, the patient displayed contralateral hip drop during single leg stance bilaterally, increased hip medial rotation on the left, and decreased balance on the left… Able to squat just passed 90° of hip flexion, but displayed increased forward trunk flexion and reported pain at and range. Hip flexion range of motion at her and range squad was 104° in the flexion range of motion was 92°.”

What this is describing is a partial squat. She is unable to go to full depth because of pain. She also has significant weakness in her hip muscles as noted during single leg stance. If you stand on 1 foot, and you notice your opposite pocket falls significantly compared to when you’re standing on both feet, then you probably have a problem in your hip ability to generate force. Sometimes we’ll see this when a person, specifically female, is walking away from us. This looks like that infamous hip wiggle. Not that I’ve ever watched! I love you babe.

“patient displayed overall hypermobility throughout the exam and had 8/9 Bieghton score for increased ligamentous laxity.”
This is otherwise known as the contortionist scale. If you could dislocate your joints at will, they probably aren’t very stable.

The intervention was actually pretty good. The authors describe meso and microcycles for endurance and strength training. This takes me back to my days as a personal trainer through the International Sports Science Association. I have yet to hear physical therapists discuss mesocycles, until this article. Essentially, they placed the patient on a progressive 2 week cycle that built upon itself over the course of 6 weeks emphasizing core stability, endurance exercises, and the addition of plyometrics.

“At the end of 6 weeks, a second reassessment was conducted. The patient stated she was now able to perform a full squat.”

Nuff said!

This is a good article because it describes that patients can improve rather quickly from functional limitations and pain when issued the appropriate interventions. One thing to note from the article is that although it took 6 weeks to improve, the patient was not treated frequently due to her schedule. The idea that a patient needs to be seen three times per week for four weeks is a tradition that needs to be questioned. As a therapist, I must place my patient’s values and health above my own needs. This is one of the core values of our profession. When I start treating you like a dollar sign, then I no longer am treating the patient according to their needs. Don’t get me wrong, some patients may need to be seen 3 times in a week, but these are few and far between in our clinic.

If you have an questions, comments, concerns or good jokes please feel free to let them fly. I can be reached through comments on this blog, @movementthinker on Facebook or at my personal page on Facebook.

Vince Gutierrez, PT, DPT, cert. MDT

Excerpts taken from:

Smith A, Brewer W. Management of Anterior Hip Pain Using a Movement System Impairment Approach: A Case Report. Orthopaedic Physical Therapy Practice. 2016;28(4):226-235.

 

Author: Dr. Vince Gutierrez, PT, cert. MDT

After having dedicated 8 years to growing my knowledge regarding the profession of physical therapy, it seems only fitting that I join the social media world in order to spread a little of the knowledge that I have gained over the years. This by no means is meant to act in place of a one-one medical consultation, but only to supplement your baseline knowledge in which to choose a practitioner for your problem. Having completed a Master of Physical Therapy degree, the MDT (Mechanical Diagnosis and Therapy) certification and currently finishing a post-graduate doctorate degree, I have spent the previous 12 years in some sort of post-baccalalaureate study. Hopefully the reader finds the information insightful and uses the information in order to make more informed healthcare decisions. MISSION STATEMENT: My personal mission statement is as follows: As a professional, I will provide a thorough assessment of your clinical presentation and symptoms in order to determine both the provocative and relieving positions and movements. The assessment process and ensuing treatment will be based on current and relevant evidence. Furthermore, I will educate the patients regarding their symptoms and their likelihood of improving with either skilled therapy, an independent exercise program, spontaneous recovery or if the patient should be referred to a separate specialist to possibly provide a more rapid resolution of symptoms. Respecting the patient’s limited resources is important and I will provide an accurate overview of the prognosis within 7 visits, again based on current research. My goal is to empower the patient in order to take charge of both the symptomatic resolution and return to full function with as little dependence on the therapist as possible. Personally, I strive to be an example for family and friends. My goal is to demonstrate that success is not a byproduct of situations, but a series of choices and actions. I will mentor those, in any way possible, that are having difficulty with the choices and actions for success. I will continue to honor my family’s “blue-collar” roots by working to excel at my chosen career and life situations. I choose to be a leader of example, and not words, all the while reducing negativity in my life. I began working towards the professional aspect of the mission statement while still in physical therapy school. By choosing an internship that emphasized patient care and empowering the patient, instead of the internship that was either closest to home or where I knew that I would have the easiest road to graduation, I took the first step towards learning how to utilize the evidence to teach patients how to reduce their symptoms. I continued this process by completing Mechanical Diagnosis and Therapy courses A-D and passing the credentialing exam. I will continue to pursue my clinical education through CEU’s on MDT and my goal is to obtain the status of Diplomat of MDT. Returning back to school for the t-DPT was a major decision for me, as resources (i.e. time and money) are limited. My choice was between saving money for the Dip MDT course (about 15,000 dollars) and continuing on with the Fellowship of American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) (about 5,000 dollars), as these courses are paired through the MDT curriculum or returning to school to work towards a Doctorate of Physical Therapy degree. I initially planned on saving for the Dip MDT and FAAOMPT, but life changes forced me to re-evaluate my situation. The decision then changed to return for the tDPT, as my employer paid for a portion of the DPT program. My goal for applying to and finishing the Dip MDT and FAAOMPT is 10 years. This is how long I anticipate that it will take to finish paying student loans and save for both programs, based on the current rate of payment. I don’t know if I will ever accomplish what I set forth in the mission statement, but I do know that it will be a forever struggle to maintain this standard that I set for myself.

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