Clinical Pearl #5: Presentation of Symptoms
Let’s move onto the discussion of onset of symptoms. It is not uncommon for patients to have pain lasting from a few to many years, intermittent episodes with varying degrees of pain. Hip pain can also present itself insidiously, “out of the blue”. It can be intense and unrelenting. Following such an episode might be a diagnosis of FAI and/or hip dysplasia once you seek appropriate care. Many individuals question: “I don’t recall any injury? What did I do to cause this? How can it be so bad I need surgery?” This can be quite frustrating, especially if the issue is not responding with time and rest. Symptoms associated with hip dysplasia, femoroacetabular impingement (FAI) or labral tears, can take months to years to present themselves, even if your symptoms are relatively new, or acute. It is acceptable to ask your physician about conservative measures such as antiinflammatory medications or possible injections for assisting with medical management of your pain. Physical therapy for various interventions for assessing dysfunctions, muscle integrity, prescribe exercises to assist with these dysfunctions, and dry needling to name a few options. Massage therapy or acupuncture may also be incorporated for decreasing pain and improving function. While none of these will change your anatomy, improving your ability to function with less pain is always optimal.
Many patients can improve significantly with the appropriate diagnosis and management of hip pain. Ignoring symptoms for years may contribute to less optimal outcomes with conservative management of your pain. The longer your body has a chance to compensate, the longer it can take to unravel these patterns to assist you.
Common Associated Symptoms Prior to Diagnosis
While you might already be in the category of having a hip diagnosis, there likely have been signs somewhere in your past. Examples include one hip not stretching into a yoga pose as much, not having the ability to increase your flexibility with certain motions on one side of your body versus the other, or “always feeling tight on that side”. This is not an exclusive list. Many of these examples are related to potential underlying FAI, but when you’re not in pain, you just think one side is tighter than the other. On the other hand, many dysplastic patients have had a lifetime of excessive flexibility.
Regarding dysplasia, there may be accompanying signs, like hyperextension of the knees and/or elbows, or the ability to reach palms to the floor on a moment’s notice. A Beighton Score, a series of joint movements performed by your physician or Physical Therapist, assesses hypermobility within the body. A higher score is often seen with patients with hip dysplasia. Clinically, there is not one specific test assessing hip instability associated with hip dysplasia. Whereas in the shoulder or knee, there are well studied, reproducible special tests assessing the stability of the respective joints. The hip does not have this same clinical testing ability to assess someone and quickly ascertain that hip dysplasia is the issue.
Lower Pelvic Floor and Pubic Symphysis Considerations
An additional area worth discussing is related to those who have no hip pain. We discussed these ideas in Clinical Pearl #3. It can be confusing if you have issues unrelated to the hip, yet ultimately be diagnosed with a hip issue. Again, remember that pain in other areas and failure to improve over time with treatment can be related to hip dysfunction. I want to come back to the lower pelvic floor and pubic symphysis areas. Lower pelvic floor dysfunction can be directly tied to hip dysfunction, especially dysplasia. It can take a tremendous amount of time seeing various specialists prior to the hip coming into conversation. If there are no hip related symptoms to report, it can be skimmed over. X-rays including the pelvis and hip area can potentially be misread by those not trained to look for hip dysplasia. And, this perpetual instability can create persistent lower pelvic floor dysfunction, or pubic symphysis pain, regardless of local interventions. As previously mentioned, if treatment interventions which should improve function and pain in these areas are not successful, then your symptoms could be related to dysfunction elsewhere. Consider the hips.
Activity Modification
Regardless of which category in which you may fall, it is important to identify if certain activities or ranges of motion relate to your pain. If sitting more than an hour increases your pain, but 45 minutes is fine, then I suggest changing positions every 45 minutes, for example. If you can identify pain free ranges with activities, performing activities which recreate less pain during or after, or shorten your activity time with less pain, you will be instrumental in improving your situation. While you may already be doing this, it’s always a good reminder!
While you might already be in the category of having a hip diagnosis, there likely have been signs somewhere in your past. Examples include one hip not stretching into a yoga pose as much, not having the ability to increase your flexibility with certain motions on one side of your body versus the other, or “always feeling tight on that side”. This is not an exclusive list. Many of these examples are related to potential underlying FAI, but when you’re not in pain, you just think one side is tighter than the other. On the other hand, many dysplastic patients have had a lifetime of excessive flexibility.
Regarding dysplasia, there may be accompanying signs, like hyperextension of the knees and/or elbows, or the ability to reach palms to the floor on a moment’s notice. A Beighton Score, a series of joint movements performed by your physician or Physical Therapist, assesses hypermobility within the body. A higher score is often seen with patients with hip dysplasia. Clinically, there is not one specific test assessing hip instability associated with hip dysplasia. Whereas in the shoulder or knee, there are well studied, reproducible special tests assessing the stability of the respective joints. The hip does not have this same clinical testing ability to assess someone and quickly ascertain that hip dysplasia is the issue.
Lower Pelvic Floor and Pubic Symphysis Considerations
An additional area worth discussing is related to those who have no hip pain. We discussed these ideas in Clinical Pearl #3. It can be confusing if you have issues unrelated to the hip, yet ultimately be diagnosed with a hip issue. Again, remember that pain in other areas and failure to improve over time with treatment can be related to hip dysfunction. I want to come back to the lower pelvic floor and pubic symphysis areas. Lower pelvic floor dysfunction can be directly tied to hip dysfunction, especially dysplasia. It can take a tremendous amount of time seeing various specialists prior to the hip coming into conversation. If there are no hip related symptoms to report, it can be skimmed over. X-rays including the pelvis and hip area can potentially be misread by those not trained to look for hip dysplasia. And, this perpetual instability can create persistent lower pelvic floor dysfunction, or pubic symphysis pain, regardless of local interventions. As previously mentioned, if treatment interventions which should improve function and pain in these areas are not successful, then your symptoms could be related to dysfunction elsewhere. Consider the hips.
Activity Modification
Regardless of which category in which you may fall, it is important to identify if certain activities or ranges of motion relate to your pain. If sitting more than an hour increases your pain, but 45 minutes is fine, then I suggest changing positions every 45 minutes, for example. If you can identify pain free ranges with activities, performing activities which recreate less pain during or after, or shorten your activity time with less pain, you will be instrumental in improving your situation. While you may already be doing this, it’s always a good reminder!