Workings Of The Hip Joint-Part 3

                                                                                         

The effect on the function of the hip joint of a difference in the length of the legs has been mentioned previously in an article in this series. The longer of the two legs will attempt to keep the head level by flexing slightly at the hip and knee, leading to a lack of movement into extension of the hip as we walk. Rotation of the hip and pelvis is required to achieve a more normal gait pattern if extension is not fully achievable. This may be a small change in joint movement, but on repetition thousands of times per day this can set up difficulties in joint movement and over time a painful joint condition.

If there is a sudden damaging event to the hip such as a strain, jar or a fall the joint can deteriorate rapidly and become much more painful very quickly. This occurs less often however than a gradual onset of pain and stiffness over a longer period of time. A trivial occurrence can set off a joint worsening, beginning with spasm of the local muscles and a loss of the typical range of extension useful in gait. Full extension is the position in which the hip is most tightly fitting and all the surrounding tissues are at their tensest, a position avoided in painful conditions.

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 major weight bearing joints of the knee and hip are mostly affected by osteoarthritic changes, osteoarthritis being the most common degenerative joint condition in the world. Many factors contribute to the incidence and severity of arthritis, with a family history being important to some degree. Osteoarthritis becomes much more prevalent with increasing age and is almost universal in some joints in older people. As the arthritis worsens the joint can gradually lose movement as the capsule tightens, with a slow healing due to the lack of good blood supply.

The smooth cartilaginous surface of the hip joint can split and thin as it degenerates, exaggerating the limp and the hip muscle spasm. An arthritic joint can suffer a rapid worsening after a small movement event and why it can do this is unknown although degrees of muscle spasm and pain may be contributory factors. The usual areas for hip joint pain referral are the fronts of the thighs, the sides of the hips, the groins and the lower areas of the buttocks. At times people consult a doctor about their painful knee and thigh and have an osteoarthritic hip.

Initial x-rays of the hip will often show little of note, the findings on x-ray may not correlate well with the levels of pain, and disability a patient is feeling. As the osteoarthritis proceeds the changes on imaging become more obvious such as a narrowing of the apparent space between the bones due to thinning of cartilage. The femoral head may become abnormally shaped and bony outgrowths develop as the joint suffers damage and attempts repair. Severe degeneration results in an unpleasant audible grating and shuddering in the joint on weight bearing.

The hip loses its ranges of joint movement typically in a predictable order with the first loss being of extension, the second of abduction (moving the legs apart out to the side) and the last internal joint rotation. On physiotherapy examination an osteoarthritic hip will be positioned forwards and be unable to extend, be laterally rotated so the foot points out and will be kept in close the middle as the outward movement has been lost. The leg shortening and inability to extend the hip during walking can mean that every step involves trunk twisting and the need to go up on tiptoe to some degree to allow for leg shortening.

About the author:
Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, Physiotherapists in Coventry, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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