What is it?
Hip bursitis is a fairly common condition, and involves inflammation of the bursae around the hip joint. The bursa are small fluid-filled sacs, and are present to reduce the friction between tendons and the bone and ensure that everything is able to move smoothly. However they can become inflamed and painful with overuse, trauma and incorrect muscle use or weakness. There are many, however the bursitis we most commonly see is the Trochanteric Hip Bursitis. The trochanteric bursa cushions the outside of the hip against the gluteal muscles (especially gluteal maximus) and the Iliotibial Band (ITB). It is the most commonly injured as these are muscles very commonly used and therefore give the bursa a lot of work!
What are the causes?
As mentioned earlier, there are a few key causes of bursitis:
Overuse (or muscles around the area) and repetitive stress – eg. With frequent running, jumping, squatting
Trauma – e.g. a fall directly onto the outside of the hip (where there isn’t much padding)
Incorrect muscle use and muscle patterns, causing altered biomechanics of the lower limb – this can also include weakness of the core muscles
Weakness in the deeper gluteal muscles (Gluteus Medius and Minimus), and tightness in the Iliotibial Band (a band that runs down the outside of the thigh). As a result of the weakness in the deeper gluteal muscles, the gluteus maximus (biggest gluteal muscle) is forced to work more than it should, and so places more pressure in the bursa, which over time causes irritation and inflammation, and pain.
Interestingly, there are recent studies to suggest that hip bursitis does not often occur on its own, and that there is commonly some element of Gluteal pathology – especially tendinopathy of the Gluteus Medius (the main stabilising glute muscle). This may be the causative reason for weakness in this area, however it is not known yet as to which comes first – the bursitis, or the tendinopathy.
What are the signs and symptoms?
Commonly, sufferers will have a sharp pain on the side of their hip (worst directly over the bony outer part of the hip, and often tender to touch). This pain may extend down towards the knee, or even upwards towards the lower back. In fact, as the lower back, hip and knee are so closely linked, it is not uncommon to see problems in all areas along with hip bursitis, including pain, stiffness and restricted movement of these areas.
Sometimes there will also be a visible swelling over the outside of the hip, or even just the feeling of swelling.
There is often difficulty lying down on the side (due to the direct pressure), or even on the unaffected side (due to the stretch). This may cause trouble with sleeping.
Walking is also aggravating, especially first thing in the morning, or after a busy day. A limp may be present. There may also be pain with sitting cross-legged, or rising out of a chair after sitting for a while.
What are the treatment options?
There are several options when it comes to improving pain and keeping the bursitis away.
Physiotherapy – this is highly successful for treating trochanteric bursitis. Initially, treatment will involve techniques to reduce the pain and swelling (eg. Ultrasound, ice, gentle massage, acupuncture, taping). Following this, your physiotherapist will aim to return full range of motion of the affected hip (and also lower back, knee if affected), correct any muscle imbalances around the hip and restore full function of the stabilising hip and core muscles, and work to eliminate any excess tightness that may be contributing to the problem. Due to the nature of trochanteric bursitis, and the danger of it recurring, a long-term program may be required.
Ice – due to the inflammatory nature of trochanteric bursitis. Ice for 15 minutes at least once per day, and also after aggravating activities
Cortisone Injections – this involves injecting a corticosteroid (anti-inflammatory) along with a local anaesthetic into the bursa in order to settle the inflammation and stimulate healing. A guided injection (usually via ultrasound) is preferred as it will assist with needle placement. Cortisone injections can be very helpful, however repeat injections have been shown affect tendon health detrimentally – it would be wise to discuss side effects with your GP.
What can I do to help?
If sleeping is a problem, it can be improved in the short term with a pillow between the legs, to level out the hips when laying on the unaffected side.
Driving can be aided by sitting slightly higher (so your hips are not as bent). This may involve lifting the seat (in newer cars), or simply sitting on a pillow. Do make sure you can still reach the pedals & drive safely however!
There are several helpful exercises that will assist in recovery and strengthening. These will ideally be performed after the initial healing phase is completed (that is, when the pain and swelling have diminished). These exercises should be performed within your comfort levels, without causing pain.
Seated gluteal stretch
Sit on edge of chair, cross one foot over the other knee, SIT UP TALL, and lean forwards
There should be a comfortable stretch in the buttocks, or even down the side/back of the leg
Hold 20 seconds, repeat 3 times each leg
Lying gluteal stretch (Single knee to chest)
Lying on your back, slowly bring one knee up towards the opposite shoulder as far as comfortable.
You should feel a gentle, comfortable stretch in your lower back, or buttocks
Hold for 10 seconds, repeat 5 times
Start on your back with knees bent (no pillow is best)
Slowly roll pelvis/hips off floor, followed by one vertebrae at a time
Aim to lower down, one vertebrae at a time
Try 10 repetitions
Prone Knee Bend
Start by lying on your tummy, feel the front of your hips on the floor.
Bend one knee to 90 degrees and then slowly lift thigh off floor (the front of your hips should stay firmly on the floor)
Once lifted, straighten your leg in the air, then slowly lower your straight leg
Repeat 10 times each leg
Start lying on your side with knees bent slightly. Make sure your shoulders, hips and feet are in a straight line.
Keep your feet together, back still and gently open your knees apart.
Repeat 10+ times on each leg, or until fatigue
* This exercise is especially helpful as it targets the Gluteus Medius
As above, make sure your body is aligned well.
This time, lift your feet up, keep your lower knee on the floor and lift your knees apart.
Repeat 10+ times on each leg, or until fatigue
A blog by Amy Mathews Amos- See below
My symptoms started in January 2008, with deep pain in my bladder and the sense that I had to urinate constantly. I was given a diagnosis of interstitial cystitis, a chronic bladder condition with no known cure. But in the following months, pain spread to my thighs, knees, hips, buttocks, abdomen and back. By the time my condition was properly diagnosed three years later, I had seen two urogynecologists, three orthopedists, six physical therapists, two manual therapists, a rheumatologist, a neurologist, a chiropractor and a homeopath.
What was wrong? Something completely unexpected, given my symptoms: myofascial pain syndrome, a condition caused by muscle fibers that contract but don’t release. That constant contraction creates knots of taut muscle, or trigger points, that send pain throughout the body, even to parts that are perfectly healthy. Most doctors have never heard of myofascial pain syndrome and few know how to treat it.
In my case, trigger points in my pelvic floor — the bowl of muscle on the bottom of the pelvis — referred pain to my bladder. Points along my thighs pulled on my knee joints, creating sharp pain when I walked. Points in my hips, buttocks and abdomen threw my pelvis and lower spine out of alignment, pushing even more pain up my back. The pain was so severe at times that I could sit for only brief periods.
“Why didn’t anybody know this?” I asked my doctor, Timothy Taylor, soon after he correctly diagnosed the reason for my pain. “Because doctors don’t specialize in muscles,” he said. “It’s the forgotten organ.”
‘There’s no wire’
Most medical schools and physical therapy programs lack instruction in myofascial pain, in part because it involves referred pain, according to Robert Gerwin, an associate professor of neurology at Johns Hopkins University. Gerwin, who is also president of Pain and Rehabilitation Medicine in Bethesda, says that medicine has only recently come to understand this type of pain.
“I remember a long conversation with a neurosurgeon saying that [referred] pain is impossible because there’s no connection, there’s no wire, no string, no blood vessel, there’s no nerve, there’s no nothing connecting these two places,” Gerwin said. Of course, the surgeon was “not realizing that the mechanism of spread is through the spinal cord.”
Pain signals from taut muscle fibers travel to specific locations on the spinal cord that also receive signals from other parts of the body. Referred pain occurs when pain signals from muscles register in the nervous system as if they came from elsewhere.
Although physicians increasingly recognize referred pain today, diagnosis and treatment of myofascial pain often takes more time than most physicians can provide, according to Taylor. Practitioners need specific training to recognize trigger points. And they must examine and palpate patients carefully to identify and locate these taut bands of muscle fiber.
In a 2000 survey, more than 88 percent of pain specialists agreed that myofascial pain syndrome was a legitimate diagnosis, but they differed over the criteria for diagnosing it.
Norman Harden, the medical director of the Center for Pain Studies at the Rehabilitation Institute of Chicago, conducted that survey. He believes that practitioners need clear, validated criteria for diagnosing myofascial pain and identifying effective treatments. He recently conducted another survey to determine if the level of recognition among pain specialists has changed. Preliminary results suggest it has not.
According to Gerwin, myofascial trigger points often cause or contribute to problems such as chronic back pain, headaches and pelvic pain. Trigger points can form anywhere in the body after an injury or if muscles brace against pain or trauma for a long period. They also can result from chronic overuse of muscles due to stress or to poor posture that puts constant pressure on muscles not designed to withstand it.
Taylor understands this as both a physician and a patient. His myofascial pain started in 2003 during his daily run. “I felt a sharp pain in my rear that felt just like when my brothers used to shoot me with our BB gun,” he recalled. He checked himself for signs of injury but found none, then limped home, assuming it was a strained muscle that would heal after a few days. It didn’t.
He sought treatment first from his general practitioner. He then went to a battery of specialists: neurologists, rheumatologists, orthopedic surgeons, osteopathic physicians, physical medicine and rehabilitation specialists, and physical therapists.
Found it on the Internet
After three years, a physical medicine and rehabilitation specialist told him the source of his pain was his piriformis muscle, a pear-shaped muscle that runs diagonally across the buttocks. The doctor prescribed stretching and strengthening exercises to resolve it, but they only made things worse. Eventually, the pain reached down to Taylor’s knees, up to his head and out to his fingers on both sides of his body.
But he finally had a useful piece of information. He did an Internet search for “piriformis muscle” — a common spot for trigger points — and “myofascial pain syndrome” popped up. “I had been to the bone doctor and the joint doctor and the nerve doctor and the rehab doctor, and none of them had really examined my muscles in great detail,” he said. And none of them identified trigger points. Taylor has since changed his focus from radiology to working toward understanding, diagnosing and treating the condition. When I met him in 2011 he had established a practice that specializes in pain syndromes.
A popular treatment is dry needling, which sounds like exactly what it is: Tiny needles are inserted into the skin to stimulate a twitch response in the heart of a trigger point, releasing it. Although similar to acupuncture, dry needling focuses directly on trigger points rather than on the meridians, or energy fields, recognized by Chinese medicine. Usually, each trigger point requires several treatments before it relaxes substantially. Between sessions, patients treat themselves each day by pressing the points against a hard surface with simple tools such as tennis balls and holding for a minute or two. Treatment also addresses posture-related strains on muscles and metabolic factors such as vitamin and mineral deficiencies, low thyroid and hormonal imbalances that can contribute to trigger points.
Though a few studies have been done, they have not adequately demonstrated the effectiveness of treatments for trigger points, according to a 2009 review published in the European Journal of Pain. Researchers at the Universities of Exeter and Plymouth and the British Medical Acupuncture Society reported that only one of the seven studies they reviewed found dry needling to be effective in reducing pain. Four other studies found no difference between dry needling and placebo treatment, and the two remaining studies had contradictory results.
The American Academy of Orthopaedic Manual Physical Therapists recognizes dry needling as a legitimate treatment. The group maintains that research shows that dry needling reduces pain and muscle tension and helps muscles with trigger points return to normal. Other studies are underway. Jay Shah of the National Institutes of Health and Lynn Gerber and Siddartha Sikdar of George Mason University are using ultrasound imaging to examine how dry needling changes the physiology of trigger points after treatment.
Gerwin says that proper training in finding the trigger points can lead to consistency in diagnosing them. He and physical therapist Jan Dommerholt of Bethesda Physiocare run Myopain Seminars, which help physicians and physical therapists learn how to diagnose and treat trigger points.
According to Harden at the Rehabilitation Institute of Chicago, without clearer diagnostic criteria accessible to general practitioners, experiences like mine will continue. “As awareness grows and doctors feel empowered to understand and make this diagnosis, then that endless and frustrating round of trying to find what I’ve got and what the answer is will stop,” he said.
Gerwin agrees that more research will help, but already he sees greater acceptance of trigger points in the medical community.
“I think the bottom line is simply that the
underlying pain physiology is understood now to explain why referred pain occurs, to understand why tenderness occurs,” he said. “And that explains a lot of what muscle pain is all about.”
In my case, through a combination of therapies, including dry needling, compression, stretching, postural changes and relaxation techniques, I feel much better. I no longer need dry needling, but I do need to practice the other techniques myself, regularly, to prevent trigger points from reforming or to release them myself when they do form.
Amy Mathews Amos, a science writer in Shepherdstown, W.V., blogs at amymathewsamos.com.
Frozen shoulder, correctly known as Adhesive Capsulitis, presents as a combination of shoulder pain and stiffness causing sleep disturbance and marked disability.
In a frozen shoulder the capsule surrounding the shoulder joint is more thickened than normal and it shrinks, adhering to the humerus (arm bone) and itself – hence the name adhesive capsulitis. It is associated with inflammation, causing pain followed by scarring, causing stiffness.
Clinical features of frozen shoulder
Gradual onset of arm pain.
Unable to lie on affected side.
Restriction of movements, usually into elevation and outward rotation.
Diagnosed by a thorough shoulder examination.
X-rays may rule out other causes of shoulder pain but are unable to diagnose a frozen shoulder.
Runs a distinct course which can be broken into 4 phases or simply “pain-predominant” and “stiffness-predominant”.
Phases of frozen shoulder
Phase 1: Usually pain.
Phase 2: Increasing pain and increasing stiffness but still predominantly pain.
Phase 3: Pain abates, leaving stiffness.
Phase 4: Resolution, usually by 2 years.
Who gets frozen shoulder?
Mostly occurs between ages 40 and 60 years.
More common in women and diabetics.
Often appears for no apparent reason but can stem from an injury to the shoulder or following shoulder surgery.
20% of patients will develop it in the other shoulder in the future but almost never occurs again in the same shoulder.
Common shoulder problems
Unable to: Reach above shoulder height
Throw a ball
Quickly reach for something
Reach behind your back e.g. doing up bra, tucking in shirt
Reach out to the side and behind e.g. reaching for seat belt
Sleep on your side
How can physiotherapy help?
Although a frozen shoulder is generally self-limiting, the aim of physiotherapy is to keep the shoulder joint as pain free and mobile as possible. Physiotherapy may also help reduce the time taken to move through each phase.
Phase 1 & 2- pain relieving techniques such as gentle mobilisation, muscle releases, dry needling, taping.
Phase 3- shoulder joint mobilisation and stretches, muscle release techniques, dry needling and exercises to regain range and strength. Treatment should not be too aggressive.
Phase 4- shoulder mobilisation and stretches followed by strength exercises to control and maintain the returning range of movement.
Headaches are a problem that affects at least 90% of us during our lifetime. There are multiple types of headaches that vary in symptoms and severity, with some of the more common types including tension-type, migraine and cervicogenic headaches. A number of headache types share common contributing factors to their source of pain, including that they often originate or are linked to the neck region. Some of the following signs may indicate that your headache may be neck related:
Pain and tension through the neck
Pain is initiated or increased with neck movement or prolonged neck posture
Neck range of motion is reduced
The pain may be more prominent or localised to one side, or may exist on both sides of the head
Pain may be experienced from the base of the skull and often refer around the skull or behind the eyes
There may be a feeling of dizziness or light headedness
History of acute trauma or repetitive trauma to the neck region
Diagnosis of headache type is critical for effective management and is an area where physiotherapists can utilise their assessment skills to help differentiate which type of headache is present. Physiotherapy invention can be very effective in managing headaches with a cervical spine (neck) related origin. A physiotherapist will assess the joints of your neck, associated muscles and neural structures to identify any abnormalities. Your posture and work ergonomics may also have a significant impact on headache development and persistence, which are areas that physiotherapists have expertise.
Physiotherapy management may include any of the following depending of your specific presentation and symptoms:
Soft tissue mobilisation/massage
Stretching of tight structures
Postural advice and correction
Strengthening of important neck stabilising muscles
Ergonomic assessment/advice for your work place set-up
Stress and tension management
If any of the above physical symptoms are sounding familiar you may find that your pain in the neck was the cause of your headache all along.