Recent Hip Injuries
For any of these hip injuries, contact us for an assessment
It is interesting to mention the possible complications involving the nervous system, since they can be precocious and manifest immediately with clinic conditions of a certain relevance or later on with more serious damages. In general, a nervous lesion appears in 1-5% of cases of pelvis fractures. The percentage increases to 18% if both the pelvic arches are interested, arriving up to a maximum of 33% when dealing with posterior acetabulum fractures accompanied by hip dislocation.
The nerve that is more commonly involved in these is the sciatic nerve.occurrences Rehabilitation will usually last from 4 to 6 months, even if some variables, such as age, need to be taken into consideration.
The main immediate symptom from the injury is pain in the thigh and inability to use the leg. It is very rare for anyone to be able to walk on a broken thigh bone and it shouldn’t be attempted. The leg is often unstable and does not move as one. Usually, the fractured leg will be shorter than the other one and distorted. There will be swelling and tenderness at the site of the fracture. There may be loss of sensation and movement of the foot if the nerve or blood supply has been affected. If the bone has come through the skin the wound will be obvious. Internal bleeding from a broken femur can be significant causing rapid heart rate and low blood pressure leading to shock.
Pain will continue to be significant for several weeks as the thigh bone heals but this will be lessened if the bone is stabilized by surgical fixation. Swelling, tenderness and massive bruising are also symptoms that often last for weeks.
What treatments should I consider?
A few years ago this type of fracture was most commonly treated in traction. However, in North America the majority of patients with a broken thigh bone are now treated by surgery. This surgery consists of straightening (reducing) the fracture and stabilizing it with a metal rod passed inside the bone and fixed to the bone at the top and bottom to prevent shortening and rotation.
Traction may be recommended in some cases where the risks of a more major operation seem too great. A metal pin is passed through the bone either just above or just below the knee. Slings and splints support the leg, and 15-25 lbs or 7-11kg of weights are attached by cords and pulleys to the pin. The principle behind using traction is that pulling on the bone both straightens it and keeps it still.
The traction must be maintained until the healing process is advanced to the point where the fracture will not move when the traction is removed. This usually takes six to eight weeks in an adult. Following this period in traction the fracture must still be protected in a body cast, otherwise it is liable to shorten, angulate or rotate. The body cast, from chest to ankle is maintained for some months until the fracture is united. If the fracture has a very stable pattern it may be possible to treat it in a cast brace after the initial period in traction.
Apart from the significant inconvenience of prolonged bed rest for traction, prolonged immobilization, and a body cast, this way of treating the fracture was found to cause a number of problems such as malunion, nonunion, stiffness, weakness and poor functional recovery from the injury.
Thus the reason for treating a fractured femur by surgery is because the results of non-operative treatment are not consistently good. Surgery is done under general or spinal anesthetic. The bone is straightened and kept straight by traction. A small hole is then made at the top of the thigh bone and a thin wire is passed down inside the bone, crossing over the fracture and into the lower fragment. The inside of the bone may be reamed (cleared out) to ensure a snug fit. Next an Intramedullary Rod (IM Rod or IM Nail) is passed over the guide wire inside the femur and is secured with screws at either end.
With some fracture patterns or with open fractures, an external fixation device may be used. To apply an external fixator, the bone is straightened and large threaded pins are passed into the bone fragments above and below the fracture. These pins are attached to a rigid framework outside the thigh, which holds the fragments in position while the healing process takes place.
When the fracture extends far down the shaft towards the knee a plate may be used. The greatest advantage of operative treatment of a fractured femur is that it allows the patient freedom to move, to walk on crutches very soon after the surgery and to leave the hospital early. The bone is not healed by the surgery, but it is held still to improve the chances of healing. The quicker recovery of normal movement of the hip and knee prevents future problems of stiffness and weakness.
Implants are often removed after the bone is healed. The external fixators are always removed. Plates are also removed quite frequently as they may give the patient some symptoms and can often be felt through the skin. Removal of IM Rods is done only when they cause symptoms. The removal operation is relatively simple and recovery is usually quite rapid (six weeks) however, the bone may need some time to regain full strength after the hardware has been removed. When there are no symptoms attributed to it, removal of the hardware is controversial. Some surgeons advocate it because the presence of a plate or a rod may weaken the bone long term; others leave the hardware in and point to the small but significant incidence of re-fracture in the three months after the implant is taken out.
What happens as I recover from surgery?
The normal uncomplicated process of bone healing takes six weeks to obtain 50 percent of eventual bone strength, three months to reach 80 percent bone strength and consolidation and remodeling of the fracture site may continue for 18 months. The consequences of this timetable are that the fracture needs protection for the first three months. Early on this means using crutches and not putting much weight through the injured leg otherwise the fixation will fail.
In order to determine when more weight can be put through the thigh your orthopaedic surgeon will monitor the healing with x-rays at intervals. When new bone formation (callus) is evident bridging across the fracture, you may be encouraged to put more weight on the leg. Even though actual bone healing may be at 50 or 80%, overall recovery from the fracture and surgery also requires adequate muscle strength and endurance as well as joint range of motion and control. Physiotherapy can help you achieve this.
Rehabilitation will begin as soon as your surgeon recommends it. Sometimes therapy will be recommended even before you are allowed to fully weight bear. In other cases, rehabilitation will not be recommended until full or nearly full weight bearing begins. Each surgeon will set his own specific restrictions based on the type of fracture, surgical procedure used, personal experience, and whether the fracture is healing as expected.
Even if physiotherapy for the injured leg has not yet begun, we highly recommend maintaining the rest of your body’s fitness with regular exercise. You can use an upper body bike if you are non-weight bearing or may even be advised to do non-weight bearing exercises in a pool. A stationary bike is often the best cardiovascular activity once weight bearing begins. Weights for the upper extremities and other leg are also strongly encouraged. Your physiotherapist can provide a program for you to maintain your general fitness while you recover from your surgery.
If you are still using crutches by the time we first see you at the Physiotherapy Clinic, your physiotherapist will ensure you are using them safely, properly, and confidently and that you are abiding by your weight bearing restrictions. We will also ensure that you can safely use your crutches on stairs. If you are no longer using crutches, or once you no longer need them, your physiotherapist will focus on normal gait re-education. Until you are able to walk without a significant limp, we recommend that you continue to use your crutches, or at least one crutch or a cane/walking stick. Improper gait can lead to a host of other pains in the knee, hip and back so it is prudent to use a walking aid until near normal walking can be achieved. Your physiotherapist will advise you regarding the appropriate time for you to be walking without any walking aid at all.
Patients may experience pain when they initially start to put weight through their leg. This pain can be from not using the joints and muscles regularly or it may be from concurrent soft tissue injury that occurred when you fractured your thigh. During your first few appointments your physiotherapist will focus on relieving your pain. We may use modalities such as heat, ice, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the surgical site or anywhere down the extremity. In addition, your physiotherapist may massage your leg and ankle to improve circulation and help decrease your pain.
The next part of our treatment will focus on regaining the range of motion and strength in your entire lower limb. Your extremity will look and feel quite weak after not using it for an extended period. Your physiotherapist will prescribe a series of stretching and strengthening exercises that you will practice in the clinic and also learn to do as part of your home exercise program. We will focus particularly on gaining range of motion in your knee as the knee can easily become stiff if early motion is not encouraged. In regards to strength we will focus on the muscles of your hip and thigh but may even give you exercises for areas such as your ankle or back as these areas help to support the lower limb when you are weight bearing. An electrical muscle stimulator may be used to assist your muscles in contracting as you do your exercises, which will assist you in more rapidly gaining your strength back. Exercises may also include stationary cycling and the use of Theraband or weights to provide some resistance for your lower leg.
If necessary your physiotherapist will mobilize your joints. This hands-on technique encourages the stiff joints of your hip, knee, ankle and foot to move gradually into their normal range of motion. Mobilization of the joints may be combined with assisted stretching of any tight muscles around the surgical site. Fortunately, the initial phases of gaining range of motion and strength after a femur fracture go quickly. You will notice improvements in the functioning of your whole leg even after just a few treatments with your physiotherapist . As your range of motion and strength improve, we will advance your exercises to ensure your rehabilitation is progressing as quickly as your body allows.
As a result of any injury, the receptors in your joints and ligaments that assist with balance and proprioception (the ability to know where your body is without looking at it) decline in function. A period of immobility and reduced weight bearing will add to this decline. If your balance and proprioception has declined, your joints and your limb as a whole will not be as efficient in its functioning and the decline may also contribute to a potential injury in the future. As a final component of our treatment your physiotherapist will prescribe exercises for you to regain balance and proprioception. These exercises might include activities such as standing on one foot or balancing on an unstable surface such as a wobble board or a soft plastic disc. Advanced exercises will include agility type exercises such as hopping, jumping or moving side to side. Eventually we will encourage exercises that mimic the quick motions of the sports or activities that you enjoy participating in.
Once the fracture shows x-ray signs of consolidation you can use the leg more normally and return to heavier activities and sports. This stage is usually between three and 18 months post-injury and depends just as much on the recovery of muscle strength and endurance as it does on the recovery of the bone. The fact that the healing process may go on for 18 months means that the symptoms of aching, throbbing, swelling and weakness may continue for a long time after the bone appears ‘healed’ on x-ray but should gradually decline and then disappear.
Generally, the strength and stiffness one experiences after surgery to repair a femur fracture responds very well to the physiotherapy we provide, however, if your pain continues longer than it should or therapy is not progressing as your physiotherapist would expect, we will ask you to follow-up with your surgeon to confirm that the surgical site is tolerating the rehabilitation well and ensure that there are no hardware issues or complications that may be impeding your recovery.
Overall the prognosis for full recovery from a fractured thigh bone is encouraging. Most people’s bones heal in a good position and they recover near normal function.
socket). Treatment options vary from conservative treatment to arthroscopic and open surgery.What Causes Femoroacetabular Impingement?
It is believed that many normal people have ‘bumps’ or slightly over-deep sockets and could potentially develop femoroacetabular impingement – this is just the way we are built and develop.
The result of these deformities is increased friction between the acetabular socket and femoral head, which may result in pain and decreased range of motion.
However, the hip has to also be provoked in some way to cause damage. This explains the tendency for athletes, sporting professionals and active people to be more susceptible to this form of injury.
FAI often presents as hip and groin pain with restricted range of hip motion.
Symptom onset can be acute, following injury, or insidious after prolonged exertion.
Pain is often provoked with prolonged sitting, walking, crossing the legs as well as during and after sport and exercise.
There will typically be a restriction in hip flexion and internal rotation range of motion.
Pain is primarily felt deep in the groin at the front of the hip, more rarely it can be on the side of the hip or the buttock.
How is Femoroacetabular Impingement Diagnosed?
Physical examination involves a series of hip tests.
Diagnosis is 90% positive with reproduction of symptoms on the impingement test – flexion adduction and internal rotation of the hip.
When testing hip range of motion there may be restriction in hip flexion and internal rotation.
Provocation of pain by flexion abduction and external rotation (FABER test) may provoke pain but is generally non-specific.
How is Femoroacetabular Impingement Treated?
An initial trial of non-operative treatment is advocated for most patients, as the pain is relatively self-limiting.
Physiotherapy can assist FAI by using a variety of techniques to:
- mobilise the hip joint that stretch any tight structures eg joint capsule or muscles
improve soft tissue flexibility and length
- strengthen the deep, intermediate and superficial hip muscles
- progress hip muscle, proprioception, joint position sense and functional control to dynamically control your hip
- Use of painkillers and anti-inflammatories may temporarily help the pain reduce the local anti-inflammatory reaction.
Hip Surgery for Femoroacetabular Impingement?
If your symptoms continue to remain unchanged on return to sport, then referral to an orthopaedic surgeon is recommended.
Surgical treatment for FAI is performed either by arthroscopic debridement or can be performed by open surgical debridement. While the techniques are quite different, the operations both aim to address the mechanical and pathological changes around the neck/acetabulum junction.
Post-FAI Hip Surgery Rehabilitation
A supervised hip rehabilitation program with your physiotherapist is an essential part of your post-surgical FAI recovery. Recovery from hip arthroscopy typically takes 3-4 months, while open hip debridement is typically 12 months. Hip arthroscopy has been the preferred method in recent years and has reported excellent results with 80% of patients asymptomatic by 3-4 months and up to 95% having improved symptoms by one year.
For more advice about femoroacetabular impingement, please ask your physiotherapist or doctor.
Piriformis syndrome is most commonly caused by your piriformis muscle overworking.
The main reasons that it overworks is due to:
- protection or dysfunction of the adjacent SIJ or hip joints.
- weakness of your deep hip stability muscles.
- overpronating feet.
How is Piriformis Syndrome Diagnosed?
In most cases , a clinical examination that excludes a lumbosacral spinal pathology as the cause of your symptoms will suspect piriformis syndrome.
Your physiotherapist will perform clinical tests to stretch the irritated piriformis or provoke sciatic nerve compression, such as the Freiberg, the Pace, and the FAIR (flexion, adduction, internal rotation) manoeuvers.
CT, MRI, ultrasound, and EMG are mostly useful in excluding conditions that could replicate piriformis syndrome. Magnetic resonance neurography can show the presence of irritation of the sciatic nerve but is rarely required.
What’s the Treatment for Piriformis Syndrome?
After a thorough assessment of your back, pelvis and hips, your physiotherapist will determine the cause of your pain.
Once your diagnosis is established, treatment could involve any of the following:
• Pelvis and spine re-alignment techniques.
•Joint mobilisation to restore normal joint mobility, range of motion and function.
•Massage or electrotherapy to help decrease pain and spasm in your piriformis and increase blood flow plus soft tissue extensibility.
•Stretching program for muscle length and flexibility
•Acupuncture or Dry Needling to reduce muscle tightness around the buttock.
•Deep core stability and hip strengthening exercises to stabilise your hip, pelvis and spine.
•Foot orthotics or exercises, if indicated by your physiotherapist or podiatrist, to help restore foot and lower extremity alignment.
What’s Your Prognosis for Piriformis Syndrome?
Piriformis syndrome is effectively treated with physiotherapy in the vast majority of cases.
Short-term symptoms can be reversed within a few days. Longstanding symptoms may take a few weeks to address the biomechanical and muscle habits that have predisposed you to the injury. Only rarely will surgery be required.
For more advice about Piriformis Syndrome please ask your physiotherapist.
There are two main groups of sacroiliac dysfunction that cause SIJ pain:
• Hypermobility / Instability
• Hypomobility / Stiffness
• Hypermobility issues are the most common and will be discussed further in this article.
• Hypomobility is normally associated with pathologies that tend to stiffen your sacroiliac joints such as in Ankylosing Spondylitis.
What Causes Sacroiliac Joint Hypermobility?
Your sacroiliac joints should move a few degrees for normal movement. Like most joints, your surrounding muscles act to stabilise your sacroiliac joints during stressful or vulnerable positions. The most important sacroiliac stabilising muscles are your deep abdominal core muscles and your deep gluteal muscle groups.
Your core muscles: specifically the transversus abdominis and oblique abdominals through their attachments to the iliac bones help closure of the pelvis and improves the position, control and stability of the sacroiliac joints.
Researchers have discovered that contraction of the transversus abdominis muscle significantly stiffens and supports your sacroiliac joints. This improvement is larger than that caused by an abdominal bracing action using all the lateral abdominal muscles. (Richardson etal 2002)
Further to this, researchers have discovered that your deep gluteal (buttock) muscles are important for controlling the lateral and rear aspects of the pelvis and hip.
When these muscle groups are weak or lack endurance your sacroiliac joints are vulnerable to excessive movement, which can lead to SIJ hypermobility dysfunction or instability and subsequent sacroiliac joint pain.
What are the Symptoms of Sacroiliac Joint Dysfunction?
Sacroiliac joint dysfunction can mimic numerous other back and hip injuries. Sacroiliac joint dysfunction can cause lower back, hip, groin, buttock and sciatic pain. Sacroiliac pain is typically worse with standing and walking and improved when lying down, but not always. It can sometimes be painful to sit cross legged and is normally painful to lie on your side for extend periods. Bending forward, stair climbing, hill climbing, and rising from a seated position can also provoke sacroiliac pain. Sacroiliac pain is sometimes reported to increase during sexual intercourse and menstruation in women.
How is Sacroiliac Joint Pain Diagnosed?
Accurately diagnosing sacroiliac joint pain & dysfunction can be difficult because SIJ symptoms can mimic other common back conditions.
X-rays are of minimal diagnostic benefit.
MRI may show signs of sacroiliac joint inflammation or eliminate other potential pathologies.
A thorough physical examination by your experienced musculoskeletal physiotherapist is the best method to assess for sacroiliac joint pain or instability.
How is Sacroiliac Joint Pain Treated?
PHASE I - SIJ Pain Relief & Joint Protection
Managing your sacroiliac pain is the main reason that you seek treatment for sacroiliac joint dysfunction. In truth, it was actually the final symptom that you developed and should be the first symptom to improve.
Managing your inflammation. Sacroiliac joint inflammation it best eased via ice therapy and techniques or exercises that deload the inflammed structures. Your doctor may recommend a course of non-steroidal anti-inflammatory drugs such as ibuprofen.
Your physiotherapist will use an array of treatment tools to reduce your sacroiliac pain and inflammation. These include: ice, electrotherapy, acupuncture, deloading taping techniques, a SIJ belt, soft tissue massage and temporary use of a mobility aid (eg cane or crutch) to off-load the affected side.
PHASE II – Restoring Normal ROM, Strength
As your pain and inflammation settles, your physiotherapist will turn their attention to restoring your normal pelvic alignment and sacroiliac joint range of motion, muscle length and resting tension, muscle strength and endurance, proprioception, balance and gait (walking pattern).
Your physiotherapist will commence you on a lower abdominal and hip core stability program to facilitate your important muscles that dynamically control and stabilise your sacroiliac joints.
Researchers have discovered the importance of your hip muscle recruitment patterns with a normal order of: deep, then intermediate and finally superficial muscle firing patterns in normal pain-free hips.
Your physiotherapist will assess your muscle recruitment pattern and prescribe the best exercises for you specific to your needs.
Please ask your physiotherapist for their advice.
PHASE III – Restoring Full Function
As your sacroiliac joint dynamic control improves, your physiotherapist will turn their attention to restoring your normal pelvic alignment and sacroiliac joint range of motion during more stressful positions and postures plus work on your muscle power, proprioception, balance and gait (walking pattern).
Depending on your chosen sport or activities of daily living, your physiotherapist will aim to restore your SIJ function to safely allow you to return to your desired activities.
Everyone has different demands for their sacroiliac joints that will determine what specific treatment goals you need to achieve. For some it be simply to walk around the block. Others may wish to run a marathon.
Your physiotherapist will tailor your sacroiliac joint rehabilitation to help you achieve your own functional goals.
PHASE IV - Preventing a Recurrence
Sacroiliac joint dysfunction does have a tendency to return. The main reason it is thought to recur is due to insufficient rehabilitation. In particular, poor compliance with deep abdominal and hip core muscle exercises. You should continue a version of these exercises routinely a few times per week. Your physiotherapist will assist you in identifying the best exercises for you to continue indefinitely.
In addition to your muscle control, your physiotherapist will assess you SIJ, spine, hip and lower limb biomechanics and correct any defects. It may be as simple as providing you with adjacent muscle exercises or some foot orthotics to address any biomechanical faults in the legs or feet. Fine tuning and maintenance of your sacroiliac joint stability and function is best achieved by addressing any deficits and learning self-management techniques. Your physiotherapist will guide you.
What is Your Prognosis for Sacroiliac Joint Pain?
The success of sacroiliac joint pain treatment via pelvic joint re-alignment and subsequent dynamic stabilisation via a deep abdominal and hip core stability control programs is very good.
We have a success rate that exceeds 90% within six weeks of commencing your treatment.
For more information please contact your physiotherapist.
Sacroiliac Joint Dysfunction Treatment Options
Sacroiliac joint instability occasionally requires additional passive support until your muscles successfully control the joint. Supportive taping is often beneficial during the initial pain reduction phase.
Longer term instability can be managed with a Sacroiiac joint stabilization belt
If you have any questions please seek the advice of your physiotherapist.
The majority of its fibres converge on the lateral edge of the psoas major and only in a minor part inserts 2,5 cm underneath the lesser trochanter of the femur. –psoas minor, that is the less important from a functional point of view, is placed in the abdomen, in front of the psoas major and it originates from the lateral facet of the body of the twelfth thoracic vertebra and first lumbar and from the interposed disc. It is a weak thoracic flexor. The main action of the iliopsoas is that of flexing the thigh on the pelvis; the psoas major intervenes in the lateral rotation and at a minor extent, in the medial rotation of the hip. Injury is a very rare occurrence and it can be a first symptom in haemophiliac patients. More common are bruises, hypo-tonicity and hypo-extensibility of this muscle. The contracture of iliopsoas is very common. manifestations.A subtle starting of pain in the iliac fossa is typical, arising when performing particular movements. It does not provoke prolonged functional iproblems, but visibly reduces the sports performance. You can sometimes hear a “click” coming from the articulation, due to hypo-sensibility of the psoas and, so, to the excessive traction on the corresponding tendon, acting as a guitar cord. The rehabilitative treatment is based on the myofascial massage of iliopsoas, recovery of extensibility and muscular strength, together with an evaluation of the piriformis muscle.
You will be able to return to sports in a short time after a specific and personalised treatment. The conservative treatment is the only type of treatment suggested when dealing with this pathology. The therapeutic process is based on: interruption of sports activity for a variable period of time according to the entity of the injury (usually no less than three months); analgesic and physical therapy for the distal injuries, laser therapy, myofascial massage, specific stretching, subsequent tone of the same muscle, gradual recovery of the specific technical gesture.
For any of these injuries, contact us for an assessment