How to help your clients with hip pain!

Hip pain can be a (literal) pain in the butt - affecting a person's activity levels and quality of life. The most common hip issue I come across in physiotherapy and the Pilates studio would have to be Greater Trochanteric Pain Syndrome (GTPS). Also known as Trochanteric Bursitis, Gluteal Tendonopathy and Lateral Hip Pain. So let’s delve into the symptoms, science and how Pilates can help.

Common symptoms you’ll hear from clients:

- Unable to lie on the affected side. Often noticed when in bed.

- Pain to the outside of the hip, often tender to touch.

- Pain running down the side of the thigh.

- Pain into the upper gluteal region, or deep buttock pain.

- Lower back pain/sacroiliac joint pain.

- Pain climbing stairs.

- Pain on standing or sitting for a prolonged period.

Once cleared by a healthcare professional, exercise therapy is the first course of action to improve strength and function for people with GTPS.  As Pilates increases in popularity amongst referrals from healthcare professionals, it places Pilates teachers in a perfect position to use their skills to help their clients.

Firstly, let’s nerd out on the science of why it occurs, and how you can apply the right exercises to alleviate and improve symptoms for those suffering.

GTPS is often caused by overload to the Gluteus Medius and Minimus muscles and their tendons. The tendon attachment lies over the Greater Trochanter bone to the side of the thigh, where there is an underlying bursa (a fluid-filled sac between the tendon and bone) which can also become inflamed and painful.

Applying load is the mainstay for building strength in muscles, tendons and ligaments over time. However, if the load becomes excessive, or repetitive and exceeds its normal capacity, injuries can occur. Tendinopathy is the most common clinical tendon condition related to overuse (1).

Whilst this can affect anyone for the aforementioned reasons, it is most common during the stages of life around perimenopause and menopause due to a reduction in blood oestrogen levels. Reduced oestrogen directly affects collagen synthesis, and is associated with reduced tensile strength & degradation of the tendons (2).

Tendons respond well to appropriate load to assist healing. So what exercises are best for this? A systematic review of 56 studies that looked at exercises that generate the highest muscle activity in the Gluteus Medius and Minimus muscles found the following to be most effective (3):

- Hip hitch/pelvic drop

- Standing hip abduction

- Single Leg Bridge

- Side-lying abduction with internal rotation of the hip

- Lateral step ups

- Resisted side steps (abduction)

- Single Leg Weight-bearing

Apologies to those clam lovers out there: Clam was the least favourable in terms of activity in the Gluteus Medius. Considered an acceptable exercise for early rehabilitation and motor control, it is not useful for strengthening. So put those clams away, and let's look at how we can use the exercises listed above, both in the Pilates studio & at home.

Here are a few exercises that I like to teach, including some challenges & progressions, depending on the person and their abilities:

Here are some points to bear in mind when seeing a client with GTPS:

1)    During the rehabilitation process (which can take several months), some discomfort during exercise is to be expected. As everyone’s injury level and pain tolerance will be different, each person must work within their limitations. I usually advise up to a 3/10 on the pain scale (10 being the worst level of pain), but no more. If the person reports pain greater than this, or pain lasts for more than 24 hours after exercise, then the load needs to be reassessed. Consider reducing exercise difficulty, resistance level and repetitions.

2)    An irritated bursa doesn’t like being squished! Compression of the bursa above the Greater Trochanter can exacerbate & prolong symptoms. Consider these simple lifestyle modifications:

-      Do not sit with your legs crossed.

-      Don’t lean into the hip when standing. Stand with weight evenly distributed through both feet.

-      In bed: lie supine with pillows under the knee.

-      Side sleepers: lie on the unaffected side, with a pillow between the knees. This prevents the top leg from crossing over.

Often symptoms respond well to appropriate exercise and small modifications. Of course, in some instances, symptoms may not improve with time and exercise, in which case you can refer to my favourite motto: “When in doubt, check it out!”. 

Sonia is a Physiotherapist and Pilates instructor, trained in both Contemporary & Classical methods. Alongside teaching, she provides bespoke consultation services for teachers seeking clinical advice & Pilates-based solutions for clients.

References:

1)    Snedeker JG, Foolen J. Tendon injury and repair - A perspective on the basic mechanisms of tendon disease and future clinical therapy. Acta Biomater. 2017 Nov;63:18-36. doi: 10.1016/j.actbio.2017.08.032. Epub 2017 Sep 1. PMID: 28867648.

2)    Frizziero A, Vittadini F, Gasparre G, Masiero S. Impact of oestrogen deficiency and aging on tendon: concise review. Muscles Ligaments Tendons J. 2014 Nov 17;4(3):324-8. PMID: 25489550; PMCID: PMC4241423. 

3)    Moore D, Semciw AI, Pizzari T. A SYSTEMATIC REVIEW AND META-ANALYSIS OF COMMON THERAPEUTIC EXERCISES THAT GENERATE HIGHEST MUSCLE ACTIVITY IN THE GLUTEUS MEDIUS AND GLUTEUS MINIMUS SEGMENTS. Int J Sports Phys Ther. 2020 Dec;15(6):856-881. doi: 10.26603/ijspt20200856. PMID: 33344003; PMCID: PMC7727410.