During this session, I had an online appointment with a new client who was complaining of hip pain and a previous patient who came in for a face to face appointment for a full objective assessment.
The first client heard a sudden pop on the right hip 2/52 when stretching before pole dancing. The pain was a dull ache (2/10 VAS) with some stiffness within the hip joint. She sometimes experiences a sharp shooting pain (5/10 VAS) but it does not occur in a particular movement. Aggravating factors include swimming (breastroke), walking downstairs, running and increasing load through the hip (5/10 VAS). Easing factors include lying down flat on back and stretching before/after pole dancing.
From the subjective assessment I found it difficult to form a clinical impression without doing an objective examination; I did find this frustrating as I was unable to decifer whether it was a joint or muscle problem. One of my clinical impressions was Femoroacetabular Impingement (FAI). Casartelli et al. (2011) evaluated hip muscle strength in young adults with symptomatic FAI and found weakness in the external rotators and abductors of the hip, but not the internal rotators (Harris-Hayes et al., 2014). Therefore, when the client comes in for a face to face appointment I can assess the strength of the muscles that are responsible for those movements using passive and resisted range of motion. Applying overpressure allows us to assess the end feel, which is the quality of motion when the segments are taken to their maximum ROM by the therapist (Haneline, Cooperstein, Young, & Birkeland, 2008). With a joint problem we would expect a hard end feel where as for muscular dysfunction it would be indicated by a soft/firm end feel. Special tests for the hip can be used to diagnose many intra and extra-articular pathologies for the hip joint (Reiman, Goode, Hegedus, Cook and Wright, 2013). The Thomas test can be used to rule out any hip flexor contracture (another clinical impression)(Vigotsky et al., 2016) Also, if I believe the pathology to be FAI or a labral tear the hip quadrant can be used or FADIRS. Subsequently, when the client comes into clinic I will perform these tests in order to create an in-depth impression of the problem.
Despite this, I prescribed the client with some home-based exercises in order for them to improve strength of the muscles around the hip.
I had spoken to this client virtually in the previous week. He had a slight increase in swelling over the joint line on the medial side and pes anserinus. This could have been because he played badminton 1/7 so caused the area to swell. Originally I advised him that if swelling flares up he should use ice and elevate the limb, however I reflected on this after and considered using the acronym PEACE and LOVE. RICE, PRICE and POLICE are widely known, however these acronyms only focus on acute management, ignoring sub acute and chronic stages of tissue healing (Dubois and Esculier, 2019). This is specific to my client as there injury occurred 8 weeks ago, therefore they are past the acute stage of healing. Protect, elevate, avoid anti inflammatory modalities, compress and educate (POLICE) can be used after injury, or in my clients case if swelling or pain increase. Load, optimism, vascularisation and exercise (LOVE) can be utilised in all other stages of tissue healing (Dubois and Esculier, 2019).
Casartelli NC, Maffiuletti NA, Item-Glatthorn JF, Staehli S, Bizzini M, Impellizzeri FM, Leunig M. 2011. Hip muscle weakness in patients with symptomatic femoroacetabular impingement. Osteoarthr Cartil 19:816–821.
Dubois, B., & Esculier, J. F. (2019). Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine, 2(54), 72-73.
Haneline, M. T., Cooperstein, R., Young, M., & Birkeland, K. (2008). Spinal motion palpation: A comparison of studies that assessed intersegmental end feel vs excursion. Journal of Manipulative and Physiolgical Therapeutics, 31(8), 616–626.
Harris-Hayes, M., Mueller, M. J., Sahrmann, S. A., Bloom, N. J., Steger-May, K., Clohisy, J. C., & Salsich, G. B. (2014). Persons with chronic hip joint pain exhibit reduced hip muscle strength. Journal of Orthopaedic & Sports Physical Therapy, 44(11), 890-898.
Reiman, M. P., Goode, A. P., Hegedus, E. J., Cook, C. E., & Wright, A. A. (2013). Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis. British Journal of Sports Medicine, 47(14), 893-902.
Vigotsky, A. D., Lehman, G. J., Beardsley, C., Contreras, B., Chung, B., & Feser, E. H. (2016). The modified Thomas test is not a valid measure of hip extension unless pelvic tilt is controlled. Peer Journal, 4(1), 2325-2334.