Osteoarthritis of the hips

Findings

Osteoarthritis(OA) commonly presents with pain in the hip or groin but it is also possible for there to be generalized thigh or knee pain but no hip pain. A low buttock ache may also be present and therefore it can be difficult to distinguish whether it is back or the hip that is causing the pain. If initial back movements, tested whilst standing, bring on the pain, then sit the patient on the couch and repeat the tests; these should then be pain-free as the hip is no longer being moved. Equally, the extreme range of normal hip movements can load the pelvis and the back and cause back pain reffered to the hip. Arthritic joint movements should hurt at the end of joint range, which may be restricted, either mechanically or by pain. The Trendelburg gate and tests might be positive. The hip should be tested with the patient sitting, lying supine and prone. The signs may be different as the joint alignment is altered in each case but, overall, passive abduction and adduction, and flexion and extension are painful and/or limited.

Cause

Degeneration of the articular cartilage, with cysts and sclerosis in the femoral head and/or acetabulum. It is possible that sportspeople are more prone to osteoarthritis, although a genetic link is also likely. The problem seems more worse with impact sports, such as running and jumping. However, in therapeutic terms, total immobilization of a joint produces articular chondral degeneration of the adjacent surfaces as no synovial fluid can flow up the nutrient cannaliculi to nourish the cartilage. Hence, rehabilitation consists of non-impact exercises to move the joint and enable synovial fluid to be squeezed up the nutrient cannaliculi.

Treatment

a)      Electrotherapeutic modalities to calm the soft tissue inflammation, such as shortwave diathermy and interferential.

b)      Maintenance of muscle  strength and fitness, by non-impact training.

c)      Injection of the hip joint with cortisone to calm any capsulitis.

d)     Sodium hyaluronate injection.

e)      Surgical replacement.

Sports

a)      An arthritic joint has to be moved inside the pain-free range but the extreme ranges of movement should be avoided. Stop stretching and stop sports and exercises that force the joint to its outer, painful range.

b)      Non- impact training can be performed on a bike, the saddle may need raising. If flexion of the hip is limited, and a rowing machine. Row within the pain- free range – by not “coming too far forward” or “laying back” too far. Whilst swimming, breaststroke should be avoided. If this is the only stroke available, then a wedge kick, rather than a full frog kick, should be utilized to avoid pain.

c)      Quadriceps strength can be maintained with closed plus open chain exercises. However, patients with osteoarthritis find open chain exercises less painfull.

d)     Golf, left arthritic hip – advise the athlete to open the stance, use more arm swing and play a fade shot. Right hip osteoarthritis restricts the swing so that a hand and arm shot is required.

e)      Tennis – restrict the play to doubles

There are two elements in the pain history, one capsular and one synovial, the other bony. The soft tissue pain has a more continuous history, often being present at rest, whereas bony is associated more with movement, and especially weight bearing. Physiotherapy, and a switch to non-impact sports, will help most people. Injection of the hip with cortisone helps the soft tissue problem and can be reserved for those with a lot of pain, but very little to see on X-ray. The injection can be repeated in special occasions, like matches, travels, holidays… Athlete for example should swing both legs when getting out of the car.

"Concise guide to sports injuries, 2^nd edition",Churchill Livingstone, Malcolm T.F. Read,  foreword by Bryan English