Physio Penrith Hip Microinstability Treatment
Treatment of Hip Microinstability at Sydney Muscle & Joint Physio Penrith
What is a hip microinstability?
Hip instability is generally defined as extraphysiologic hip motion that causes pain with or without symptoms of hip joint unsteadiness. Symptomatic hip microinstability has not received as much attention, as it is more poorly defined, has a less dramatic clinical presentation, lacks consistent objective evaluative criteria, and it has only recently emerged as a significant cause of pain and disability in younger patients and athletes.
The proposed pathomechanism of hip microinstability begins with subtle anatomic abnormalities in the presence of repetitive hip joint rotation and axial loading as seen in sports such as golf, football, tennis and baseball. Alternatively, it may be the result of inherent ligamentous laxity and/or peri-articular muscular weakness. This results in increased movement of the femoral head relative to the acetabulum and eventual damage to the labrum, cartilage and capsular structures.
What are the symptoms of a hip microinstability
Most patients with idiopathic hip microinstability have a chief complaint of hip pain, although some will note apprehension or a sense of giving way during certain activities. Special attention should be given to symptoms brought on by activities requiring repetitive hip rotation and axial loading, such as those seen in sports noted earlier. Often the hip pain has an insidious onset and gradually worsening of symptoms without a specific history of trauma.
How do you diagnose a hip microinstability?
The goal during the physical exam should be to reproduce the patient’s symptoms, whether pain or apprehension, with range of motion, or provocative tests. Pain as a result of intra-articular hip pathology, such as hip microminstability, is generally localised to the groin, buttock, thigh, or in the ‘C sign’ distribution and usually cannot be reproduced with palpation. Hip strength and range of motion should be evaluated, and special attention should be made to the spine, abdomen and knee to rule-out associated pathology and/or a referred source of symptoms.
Excessive internal or external rotation of the hip (>60° in either direction), and/or lateral knee joint line <3 inches from the examination table during FABER may be suggestive of increased laxity of the hip joint. The presence of generalised ligamentous laxity/hypermobility should be assessed using the Beighton criteria
The anterior impingement test can be used to diagnose intra-articular hip joint pain (including FAI or acetabular retroversion). In addition, five specific provocative tests have been described to evaluate for hip instability:
The log roll test - performed with the patient relaxed in the supine position, the examiner internally rotates the foot past neutral (straight up) and removes pressure from the foot. The foot will then fall back into external rotation. External rotation greater than the contralateral side may suggest anterior capsular laxity (especially if the foot-table angle is <20°) and can be considered a positive test.
Anterior apprehension test - performed with the patient in the supine position with the buttocks just to the edge of the examination table- the affected lower extremity is then extended (although the patient holds the contralateral extremity in flexion) and externally rotated. The maneuver stresses the anterior hip capsule, and a positive test reproduces anterior hip pain and/or apprehension.
Posterior apprehension test - performed with the patient in the supine position with the affected hip in 90° of flexion, adduction and internal rotation. A posteriorly directed force is then applied and a positive test reproduces pain and/or apprehension.
Prone external rotation test - performed with the patient prone and the affected hip maximally externally rotated with anteriorly directed pressure on the posterior greater trochanter to translate the femoral head anteriorly. A positive test reproduces the patient’s symptoms in this position.
Abduction-extension-external rotation test - performed with the patient in the lateral position with the affected side up, and the hip abducted to 30° and externally rotated. Pressure is placed on the posterior aspect of the greater trochanter and the leg is slowly extended from 10° of flexion to full extension while applying an anteriorly directed force through the greater trochanter, with a positive test reproducing the patient’s symptoms.
What is evidence-based treatment of hip microinstability?
In general the treatment for patients with hip pain and evidence of microinstability usually begins with an extensive course of non-operative management. This includes activity modification, oral anti-inflammatory medications and a course of formal physical therapy with a focus on strengthening of the iliopsoas, hip abductors, short external rotators, abdominal core muscles and low back. Stretching is generally not supported for conditions involving instability and as such our physios and exercise physiologists do not prescribe stretching, as well as foam rolling or the use of massage balls. Heavy slow resistance, getting long and strong (eccentric) and the specific use of mechanotransduction is the only way to reduce pain, improve stability and increase resilience.
In patients with an underlying connective tissue disorder, we also often recommend an extended course of non-operative management as a result of their abnormal collagen biology.