The Hip - Part Three

By Jonathan Blood Smyth

We looked at the relevance of a discrepancy in length of leg on the ability to use the hip in a previous article. The leg which is the longer has to stay slightly bent to manage to keep the eyes and head level, preventing the hip from achieving full extension as we take each step. The inability of the hip joint to move back into full extension ensures it has to rotate an amount to achieve the walking pattern required. As an occasional problem this may not be significant, but when multiplied by the thousands of steps we take each day it can develop a painful condition with restriction of joint movement.

A sudden injuring event such as a sprain, fall or jar can cause a sudden worsening of the condition of the hip, with much increased pain and reduction in movement. It is however more likely that the hip will become gradually more troublesome with time. A minor mechanical upset can set off an exacerbation of the joint with a loss of the normal range of motion into extension and some muscle spasm. In extension the hip is in what is called full pack, where the surrounding tissues are tightest and the joint is most closely fitting, typically avoided by anyone with a painful hip.

A limp is a normal development when one has a painful hip and this is commonly observed with arthritic hips and knees. Once a limp has been present for some time it is difficult to get rid of it. The stresses which occur across the hip joint are greatly altered by a limp, with abnormal muscle use and a gradual tightening of the ranges of movement. The capsule of the hip can be progressively tightened by this process and this is why a normal gait is the aim of all physiotherapists who are assessing and managing a lower limb condition.

The most common degenerative condition in the world's population is osteoarthritis, which commonly affects the knees and hips. There are many reasons for the onset and progression of osteoarthritis but a history in the family is known to be of some importance. As people get older the occurrence of osteoarthritis rises until in old age virtually everyone has one of more arthritic joints. As the osteoarthritis worsens the joint capsule can tighten up steadily and the healing process in this area is slow due to a low blood supply.

The steady loss of the articular surface of the hip goes on with an increased limp and consequent spasm of the hip muscles. There can be a rapid deterioration of an arthritic joint without much of a mechanical insult and it is not understood exactly why, but elevated levels of muscle spasm and pain may contribute. Pain from a hip joint refers to the anterior thigh region, the groin, the side of the hip or the lower buttock. Patients may attend a medical consultation with what they expect is a leg or knee condition and are surprised with a diagnosis of an arthritic hip.

Little useful information may come from x-rays of the hip in the early stages of osteoarthritis and the patients disability or pain is not easily connected with x-ray findings overall. A worsening joint will show clear x-ray changes such as narrowing of the joint space caused by loss of thickness of the articular cartilage. Abnormal shaping of the femoral head and the formation of marginal joint bone outgrowths called osteophytes will occur in severe cases. On bearing weight or movement a severely osteoarthritic joint will shudder and grate audibly.

There is a particular order in which the restrictions of joint movement develop in the hip joint. The first movement lost is extension, followed by moving the hip outwards (abduction) and finally of the ability to turn the thigh inwards (internal rotation). On examination by a physiotherapist the hip will present turned outwards, close to the midline as moving it away is difficult and held in slight flexion due to the loss of extension. As the leg cannot be extended in walking and the leg is shorter than the other side each step of gait necessitates a trunk twist and a small toe raise to allow for the abnormalities. - 32188

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