Physical Therapy for Hip Impingement
Hip impingement is a structural or mechanical disorder of the hip that involves a change in the shape of the surface of the hip joint, leading to stiffness, pain, and damage to tissue and bone. Hip impingement can result from excessive contact between the ball and socket of the hip joint, a structural variation in the shape of the bones of the hip, or changes in muscle length and activation at the hip. Physical therapy helps patients with hip impingement regain movement, flexibility, and strength in the hip and return to regular activities and sports safely through a hip strengthening and core stabilization exercise program.
Anatomy of the Hip
The hip is a ball and socket joint, comprised of the acetabulum (the socket) and the head of the femur (the ball). The hip socket is housed in the pelvic bone and is lined by a ring of cartilage (the hip labrum) that stabilizes the hip joint. The head of the femur is a spherical structure that fits flush into the hip socket. Between the hip socket and the femoral head, there is broad contact and a secure and robust fit.
Ligaments connect the femoral head to the socket, stabilizing the hip and forming the joint capsule. The joint is lubricated by synovium fluid and bursae. The hip joint is surrounded by muscles that support the hip and enable movement, including the gluteal muscles, abductor muscles, hip flexors, quadriceps, and hamstrings.
What is Hip Impingement?
Hip impingement (or femoroacetabular impingement, FAI) is a structural or mechanical disorder of the hip that involves a change in the shape of the surface of the hip joint, leading to stiffness, pain, and damage to tissue and bone. Hip impingement can result from excessive contact between the ball and socket of the hip joint, a structural variation in the shape of the bones of the hip, or changes in muscle length and activation at the hip. This can lead to bony changes or deformities that pinch or compress bone, cartilage, and other joint structures.
There are three different types of hip impingement:
Cam impingement: this is a structural issue in which the femoral head is not perfectly round but instead is oval-shaped which interferes with the femoral head’s ability to move smoothly within the socket. The abnormally shaped femoral head creates friction when the ball hits the edge of the socket.
Pincer impingement: this is a structural issue in which the hip socket is overdeveloped, and the extra bone of the hip socket pinches the femoral head as it moves through the socket. The socket may cover the head too much, creating friction when the edge of the cup hits the head and neck of the femur. Typically, the hip is angled forward; however, with a pincer impingement, the hip may be angled toward the back, or a protruding bone develops on the pelvis, making the hip socket deeper. The labrum is pinched, especially when flexing the hip, which can lead to a labrum tear over time.
Adaptive impingement: this is a result of dysfunctional posture and muscle strength, which contributes to compression by the femoral head on structures at the front of the hip.
Symptoms of hip impingement can include:
Pain that begins gradually, worsening over time, at the front and side of the hip
Groin pain or discomfort at the outside of the hip or along the thigh, buttocks, or low back
Structural limitations or pain when flexing the hip above a 90-degree angle
Sharp, stabbing pain when squatting, sitting, standing, or performing athletic moves like running, cutting, jumping, twisting, pivoting, and moving side to side
Loss of motion or feeling of stiffness when rotating the leg inward or when lifting the leg
Pain in the hip that increases after sitting for long periods or leaning forward
Popping, clicking or grinding in the hip during movements which can be associated with damage to the labrum because of repetitive impingement
For many with hip impingement, it is thought that the abnormal shape of either the ball or socket of the hip joint is present since birth. However, the abnormal shape can develop over time and is seen more frequently in young athletes who participate in sports involving a lot of twisting of the hip and squatting. Hip impingement usually affects those under the age of 50.
Physical Therapy for Hip Impingement
Physical therapy helps patients with hip impingement regain movement, flexibility, and strength in the hip and return to regular activities and sports safely. At the start of physical therapy for hip impingement, the physical therapist conducts a thorough evaluation, including an assessment of gait, movement quality, range of motion, flexibility, and strength of the hips, trunk, and lower extremities as well as lower extremity balance and coordination. From there, the therapist designs a customized treatment program to address individual limitations, ease pain, and improve overall function.
Physical therapy treatment for hip impingement can include:
Manual therapy:
Soft tissue mobilizations: hands-on treatment of the muscles surrounding the hip to reduce pain, improve muscle relaxation, and improve the ability of joints to move normally.
Joint manipulation: hands-on treatment of the hip joint to improve joint-specific mobility and proper joint movement.
Flexibility training and stretching tight muscles of the hip and lower extremities (trunk, leg ankle, or foot) to decrease stress at the hip.
Targeted strengthening of the hip, gluteal, and leg muscles to take the stress off the hip and address any muscular imbalances. Gluteal muscle strengthening is key as they play an important role in alleviating compression and pinching in the hip.
Core stabilization through the strengthening of abdominal and low back muscles that attach to the pelvis to restore core and pelvic control. Strengthening the lower abdominal muscles is key as they maintain proper pelvic and spine positioning.
Balance and proprioception training: training on uneven surfaces to gain greater stability, control, and alignment of the pelvis and trunk.
Neuromuscular re-education: targeted training of faulty movement patterns to improve muscle coordination and facilitate muscle activation in muscles that are weak or inhibited.
Activity modification: the therapist addresses potential aggravating activities by changing the way the patient sits, stands, and moves in daily activities to take the stress off the hip joint.
Research has shown that exercise can help individuals fully recover and manage future episodes of pain from hip impingement, particularly targeted hip strengthening and stretching and core stabilization training. A 2019 review assessing 100 patients in 5 clinical trials found that physical therapy-guided exercise is the most effective treatment for hip impingement, particularly exercise programs that include hip and core muscle strengthening.
For most cases of hip impingement, physical therapy is recommended first. If surgery is in fact necessary, pre-surgical rehabilitation is key to strengthening and supporting the joint and reducing post-surgical recovery time. Surgery for hip impingement involves a hip scope in which the surgeon addresses the abnormality in the joint while preserving healthy tissue in the hip. Post-surgical rehabilitation is essential to regain mobility and strength in the hip.
Are you experiencing persistent hip pain? Start working with a physical therapist to reduce pain and restore mobility in your hip to return to your activities and sport!
