Preserving your hip - age 50-90.

Hip pain after 50 is common, and is often poorly managed in the early stages. As a system, we are great at treating a severely arthritic, painful hip at it's end-stage. We simply replace it with surgery and in most cases, the pain goes away and you get your life back. This is a classic example of what some call "Medicine 2.0" - the identification of disease, and the subsequent treatment of it. This is how our grandparents and parents treated their "arthritic hips". The future is going to look different.

There is a new approach that's been labeled "Medicine 3.0" whereby we identifty a disease in it's earliest stages, and then treat it with simple, non-invasice therapy to ensure it does not then become a problem. The future of hip care in the older adult will rarely involve surgical replacement because we'll get going early on properly treating the hip and ensuring it does not progress and deteriorate. Let's start by talking briefly about what goes wrong with the hip. (if you just want to skip to the part on how to treat the hip, click here)

Hip pain in the older adult typically presents in 2 forms:

The hip joint itself is closest to the surface at the front of your hip, just below the crease where your leg becomes your belly.

A) Swelling deep within the actual ball-and-socket hip joint itself.

Most (but not all) cases of swelling within the joint show up as pain in the front of the hip, or the groin region. Many people point to this location and call this their "hip flexors". Indeed, 2 of the key muscles that flex the hip are located in this region. Research tells us that, in the majority of cases of pain in the front of your hip, it is not in fact the hip flexors that are causing the pain, but the hip joint itself. When you have pain in this region, we start by assuming there is something irritated in the hip joint itself, until we can prove otherwise.

B) Pain (with or without swelling) in the muscles, tendons and bursae around the hip joint.

The "greater trochanter" on the outside of the hip

Sometimes the hip joint itself is not swollen or painful at all, but the pain is coming from structures outside and around the hip joint. The pain may be in the front of the hip, but it may also be in the very outside of the hip, right where your wrist would be if you were a soldier standing at attention. There is a large bone here that serves as a major attachment point for many muscles.

There are also a number of key muscles in the outside-back of your hip, right where the back pocket of your jeans would be. Many people refer to this as their "glutes" but it's important to remember that there are 3 unique "glute" muscles, and each has a very different function, and each must be exercised in it's own unique way.

Pain in the region of the greater trochanter can come from a number of sources.

Diagnosis of hip pain

There are 3 important things to consider when we diagnose why your hip is hurting, and (spoiler alert), x-rays and other imaging are the least important.

First, we take a thorough history. You'll need to tell us as much as you can about how your pain started and progressed, and how it behaves each day. We'll pick apart every detail like Sherlock Holmes looking for clues. Many diagnoses can be confidently made from the story you tell.

Secondly, we'll examine your hip. That usually requires disrobing into shorts or a gown, and anywhere from 10-20 minutes worth of hands-on testing. There is a large amount of information we can get from testing how your hip moves, and how your ligaments and muscles are functioning. Generally, we can be quite confident in the diagnosis after taking your history and completing the exam.

Occasionally, some type of xray or scan is necessary to confirm. Keep in mind that an image can only be interpretted properly when correlated with the exam findings. If the person who sent you for the image did not examine your hip for more than a minute or two, it would be very hard for them to interpret the imgaing results properly.

Medicine 3.0: How to preserve your hip past 50:

Whether your pain is coming from inside the hip joint, or outside the joint, it's likely developed because of abnormal wear and tear that you have control over. Here's a quick primer on what that looks like.

The primary function of your hip is to balance your body weight when standing on one leg. That's what walking is - a repetitive one-legged balance activity. (Running is the same, but with a much higher joint load.)

In order to do this properly, your body need to keep the pelvis level when you are standing on one leg. Follow the simple physics here:

When standing on both legs, the line of gravity is going through the centre of your body, and there is equal weight on both hips. Standing still on both legs is very easy on the hip joint.

Body weight is equally through both hips. The pelvis is level and balanced.

When standing on one leg, the pelvis is no longer supported on the one side. Can you see how the pelvis is now tending to tilt to the side, and "drop" on the side of the leg that is off the ground. It's like a table missing one leg. It's going to tilt.

In order to prevent this, you have hip muscles that pull hard on the pelvis to keep it level. The key muscles that do this are your Gluteus Medius and your TFL.

But your hip is incredibly well designed, and it knows that when one muscle pulls hard, other muscles have to counterbalance that, in order to keep the hip ball centred in the socket. The combination of 12 or more distinct muscles, working together is what keeps the hip functioning well for an entire lifespan.

Here's the key problem that leads to a hip wearing out:

Unless you maintain sufficient strength in each and every hip muscle, some start to get weak over time. When they do, your hip finds some other way to balance everything. Some structures start to do a job they weren't designed for (bursa, tendon, labrum). They can manage that for some time, even for years, but the wear and tear begins and progresses.

To repeat, your hip tends to wear out when it is no longer deeply balanced in the socket, and starts to drift away from centre, rubbing on cartilage, overstraining ligaments or bursae and overworking muscles.

Sounds discouraging. Here's how to reverse that.

Let's simplify as much as we can. You need to consider 2 options to take the strain off your hip:

A) Load management.

We can reduce the load that you place on your hip in a number of ways. The right approach is specific to each individual, and may include some combination of the following:

• temporary use of a cane or walking poles.

• changing the way you stand

• avoiding crossing your legs when sitting

• changing your chosen activities. (Below is a list of activities and the load they place on your lower extremities. You may need to move from the red and orange zone into the green zone for some time, or permanently.

Journal of Orthopedic and Sports Physical Therapy, Vol 33, No 10.  October 2003

B) Regaining proper hip strength and control through exercise.

Learning how to move your hip properly is very helpful for slowing down or stopping the wear and tear on your hip joint. Everyone is a bit different, and we'll need to find out which exercises you need.

Proper hip strengthening requires a precise assessment and the prescription of very specific exercises. If your hip is in the very early stages and only a bit sore, we'll spend time correcting the weakness that has developed. Sometimes a painful hip just needs some very high level strengthening and balance work, done for a month or two.  If you are in really quite a lot of pain and finding it very hard to move, it's going to take longer. We'll start with bed exercises; things you can do easily while lying down, without much effort. I'll trial different things with you over a few visits, until we find exactly the right approach. Then we'll progress through medium and then high-level exercises over many months. Remember, your hip can be weak for many years before you start to have symptoms. It takes months to reverse that.

 There are no "BEST HIP EXERCISES" that work for everyone.

Eventually, we'll arrive at an ongoing "maintenance program" that you'll do on your own for up to a year. The exercises we start with are almost never the exercises we end with. It's like learning piano - you start with simple tunes, and once you master them you move on to the more challenging ones.

The future of hip preservation

In addition to exercise-based rehab, there are other therapies that will help preserve your hip (things like hands-on treatment, joint injections, dietary changes). That's outside the scope of this blog. But the most important joint preservation activity you're going to need in order to preserve your hip for decades more is strengthening your hip back to it's normal state and changing the load your place on it with your chosen activities.

Note about the author:

I've been working with osteoarthritis of the hip for more than 25 years. I see patients in their 20s who are already in the queue for hip replacement, and I see middle age and older adults who are slowly heading toward the same. Some folks arrive at my clinic already diagnosed. Others show up with a tricky hip problem, not sure what it is, and with a thorough examination and perhaps some imaging, we make the diagnosis here. (Although I treat all types of injuries from the jaw to the toes, I have a deep interest in hip pain).

Jeffrey Begg, PT

*This advice is specific to some patients. I will direct you to this page if this applies to you. This is not generic advice about all cases of hip pain.