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
Does running accelerate the development of osteoarthritis?
There are so many misconceptions about running and how bad it can be for your joints. You may have heard many friends and family members comment on this and they may have even tried to convince you to stop running and go swimming instead. Here is what the scientific research tells us so far:
Osteoarthritis (OA) is a musculoskeletal condition that involves degeneration of the joints and impact during weightbearing exercise such as running and may contribute to joint loads. There is very little evidence however, that running causes OA in the knees or hips. One study reported in 1985 by Sohn and Micheli compared incidence of hip and knee pain and surgery over 25 years in 504 former cross-country runners. Only 0.8% of the runners needed surgery for OA in this time and the researchers concluded that moderate running (25.4 miles/week on average) was not associated with increased incidence of OA.
In another smaller study of 35 older runners and 38 controls with a mean age of 63 years, researchers looked at progression of OA over 5 years in the hands, lumbar spine and knees (Lane et al. 1993) . They used questionnaires and x-rays as measurement tools. In a span of 5 years, both groups had some participants who developed OA- but found that running did not increase the rate of OA in the knees. They reported that the 12% risk of developing knee OA in their group could be attributed to aging and not to running. In 2008, a group of researchers reported results from a longitudinal study in which 45 long distance runners and 53 non-runners were followed for 21 years. Assessment of their knee X-Rays, revealed that runners did not have a higher risk of developing OA than the non-running control group. They did note however, that the subjects with worse OA on x-ray also had higher BMI (Body Mass Index) and some early arthritic change in their knees at the outset of the study.
Is it better to walk than to run?
It is a common belief that it must be better to walk than to run to protect your joints. In a recent study comparing the effects of running and walking on the development of OA and hip replacement risk, the incidence of hip OA was 2.6% in the running group, compared with 4.7% in the walking group (Williams et al 2013). The percentage of walkers who eventually required a hip replacement was 0.7%, while in the running group, it was lower at 0.3%. Although the incidence is small, the authors suggest the chance of runners developing OA of the hip is less than walkers.
In the same study, Williams and colleagues reinforced that running actually helped keep middle-age weight gain down. As excess weight may correlate with increased risk of developing OA, running may reduce the risks of OA. The relationship between bodyweight and knee OA has been well-established in scientific studies, so running for fitness and keeping your weight under control is much less likely to wear out your knees than being inactive and carrying excess weight.
Is there a limit?
Recent studies have shown that we should be doing 30 minutes of moderate exercise daily to prevent cardiovascular disease and diabetes. But with running, researchers still have not established the exact dosage of runners that has optimal health effects. Hansen and colleagues’ review of the evidence to date reported that the current literature is inconclusive about the possible relationship about running volume and development of OA but suggested that physiotherapists can help runners by correcting gait abnormalities, treating injuries appropriately and encouraging them to keep the BMI down.
We still do not know how much is “too much” for our joints. However, we do know that with age, we expect degenerative changes to occur in the joints whether we run or not. Osteoarthritis is just as common as getting grey hair. The important thing is that we keep the joints as happy and healthy as possible.
How do you start running?
If you are not a runner and would like to start running, walking would be a good way to start and then work your way up to short running intervals and then longer intervals as you improve your fitness and allow time for your body to adapt. Therefore, running in general is not bad for the joints. It does not seem to increase our risk of developing OA in the hips and knees. But the way you run, the way you train and how fast you change your running frequency and distance may play a role in future injuries of the joints.
Knee pain can affect a large range of age groups, ranging from ‘growing’ pains experienced by young people to ‘arthritic’ pain in older persons, and everything in-between. In this Blog we will examine knee meniscus injuries, what causes them and how to treat these injuries.
What is the Meniscus of the Knee?
The meniscus are C-shaped structures in your knee joint which sit between your femur (or thigh bone) and your tibia (or shin bone). They are made of a type of cartilage called fibrocartilage, which is a little bit different to other form of cartilage in your knee called articular cartilage. Articular cartilage is often more affected with arthritis. Your knee has two menisci, the medial meniscus and lateral meniscus. The medial meniscus is located on the inside while the lateral meniscus is on the outside of your knee.
The menisci have a limited blood supply which rely on movement of the knee to keep it strong and healthy. The best thing you can do to prevent your meniscus from injury, is to keep active and keep the knee moving.
What does the Meniscus do?
The main role of the menisci is to help with absorbing and distributing forces through the knee joint. They work together with knee and hip muscles to act as a shock absorber when the knee is active. The menisci also increases the surface area of the knee joint, so it adds some extra stability to the knee.
How do you injure your meniscus?
The majority of meniscus injuries occur as people age (over 50 years). As you get older the limited blood supply to the meniscus becomes further reduced. As people age they develop wrinkles and grey hair. The aging process also occurs in the knee, the menisci begin to degenerate, lose some of their strength and become more prone to injury.
As the menisci become more susceptible to injury with age, the range and types of movements which can damage it become more prevalent. The majority of meniscus injuries occur when you twist your knee over a planted foot. – Sometimes it can be as simple, as turning to look over your shoulder or stepping off a ladder and putting weight on your foot and twisting your knee. You might notice the knee to slowly swell up.
Meniscus injuries in the younger ager group (under 30) are not as prevalent. Simple twisting movements to the knee are unlikely to cause menisci injury in younger persons. You are more likely to see menisci injuries occur with other knee injuries such as ligament damage caused through sport.
What should I do if I damage my meniscus?
So you have injured your knee and you are thinking, what to do next? Alternatively, you have had a scan on your knee and been diagnosed with a meniscus tear and wanting to know what is the best way to treat it?
A 2002 study involving people who had ‘degenerative’ menisci tears, compared the rehabilitation recovery rates of three groups. The first group had meniscus removal surgery (i.e. arthroscopic meniscectomy), the second experienced joint ‘wash-out’ (lavage) and third underwent ‘placebo’ surgery where the surgeon made skin incisions only. All groups undertook the same rehabilitation program. Amazingly they found no difference in between the 3 groups. All groups had the same levels of pain and function, and all improved at the same rate.
Since the initial 2002 study, further published studies have compared meniscus surgery with placebo surgery and physiotherapy treatment. These studies continue to confirm the same result, that is, there is no differences between all of the groups in terms of rehabilitation other than the surgery group having a higher cost of treatment!
The treatment for meniscus tears in the active, younger population (under 30) is more complex with some individuals needing surgery as soon as possible, while others can manage with physiotherapy and exercise.
What does this all mean?
Degenerative meniscus tears are more common as people age. In some cases people who not have any knee pain may have degenerative menisci and not be in any pain. In other words having a degenerative meniscus correlates poorly pain. The good news is, you might not need to have surgery at all if you are able to undertake a comprehensive physiotherapy rehabilitation program.
Will surgery provide you any benefits? Yes it will in the short term. However, arthroscopic meniscus surgery is associated with a ten-fold increase the risk of knee osteoarthritis.
Although most degenerative meniscus tears don’t need surgery, there are always some cases where surgery is going to be more effective than physiotherapy. Some menisci tears can either ‘stick-up’ into the joint or ‘break-off.’ In cases like these the tear can cause the knee to lock when trying to bend or straighten, and surgery is recommended to remove the tear.
What will my physiotherapist work on during my rehabilitation?
The first thing your physiotherapist will undertake is a full assessment of not only your knee, but your legs and even your back to see if you pain is coming from your meniscus or from somewhere else.
If you have hurt your meniscus recently your physiotherapist will start treatment aiming to reduce the swelling and begin to return it to its full range of movement.
If you have full range of movement and no swelling in your knee joint your physiotherapist will begin an exercise program focused on strengthening the muscles around your knee, and from around your hip. Weak quadriceps muscle has been found to place a greater load on your knee joint and your meniscus. Strengthening these muscle groups can reduce the pressure on the meniscus during movement. Weakness in your bottom (gluteal) muscles can also affect your knee function. Weakness in the gluteal muscles is known to place more load through the inside of the knee, which is where the majority of medial injuries occur. Strengthening the quadriceps and gluteal muscles will contribute to reducing the pressure on the knee.
Degenerative meniscus tears areas common as wrinkles and grey hair as you grow older. Although surgery is sometimes required for some knee injuries it often is not the only or best option in most cases. For most knee injuries involving the menisci the best anti-aging medicine is physical activity and exercise.
Tendinopathy TOP TEN By Jill Cook PhD
Tendon pain and dysfunction are the presenting clinical features of tendinopathy. Research has investigated many treatment options, but consistent, positive, clinical outcomes remain elusive. We know that treatment should be active (eg, exercise-based), and that a consistent and ongoing investment in rehabilitation is required. It is important to maximise this investment by understanding (and conveying to patients) treatments that do not help. The following 10 points high- light treatment approaches to avoid as they do not improve lower limb tendinopathy.
1. Don’t rest completely.
Rest decreases the load tolerance of tendon, and complete rest decreases tendon stiffness within 2 weeks.1 It also decreases strength and power in the muscle attached to the tendon and the function of the kinetic chain,2 and likely changes the motor cortex, leaving the person less able to tolerate load at multiple levels. Treatment should initially reduce painful, high tendon load (point 2) and intro- duce beneficial loads (eg, isometrics3). Once pain is low and stable (consistent on a loading test each day), load can be increased slowly to improve the capacity of the tendon.4
2. Don’t prescribe incorrect exercise.
Understanding load is essential for correct exercise prescription. High tendon load occurs when it is used like a spring, such as in jumping, changing direction and sprinting.5 Tendon springs must be loaded quickly to be effective, so slow exercises even with weights are not high tendon load and can be used early in rehabilitation. However, exercising at a longer muscle tendon length can compress the tendon at its insertion.6 This adds substantial load and should be avoided, even slowly, early in rehabilitation.
3. Don’t rely on passive treatments.
Passive treatments are not helpful in the long term as they promote the patient as a passive recipient of care and do not increase the load tolerance of tendon.Treatments like electrotherapy and ice temporarily ameliorate pain only for it to return when the tendon is loaded.7
4. Avoid injection therapies.
Injections of substances into a tendon have been shown to be no more effective than placebo in good clinical trials.8 Clinicians who support injection therapies incorrectly suggest they will return a pathological tendon to normal. There is little need to intervene in the pathology as
there is evidence that the tendonadapts to the pathology and has plenty of tendon tissue capable of tolerating high load.9 Injections may change pain in the short term as they may affect the nerves, but should only be considered if the tendon has not responded to a good exercise-based programme.
5. Don’t ignore tendon pain. Pain usually increases 24 hours afterexcess tendon load. An increase in pain of 2 or more (out of 10) on a daily loading test should initiate a reduction in the aspects of training that are overloading the tendon (point 2). The overload is likely to be due to excessive spring-like movements such as jumping, running and changing direction.
6. Don’t stretch the tendon.
Aside from the load on a tendon in sport, there are compressive loads on the bone-tendon junction when it is at its longest length. Stretching only serves to add compressive loads that are detrimental to the tendon.10
7. Don’t use friction massage.
A painful tendon is overloaded and irritated (reactive tendon pathology). Massaging or frictioning the tendon can increase pain and will not help pathology.7 An effect on local nerves may reduce pain in the short term only for it to return with high tendon loads.
8. Don’t use tendon images for diagnosis, prognosis or as an outcome measure.
Abnormal tendon images (ultrasound and MRI) in isolation do not support a diagnosis of tendon pain as asymptom- atic pathology is prevalent. There are also no aspects of imaging, such as vascu- larity and ‘tears’, that allow a clinician to determine outcome.11 Pathology on imaging is usually very stable and does not change with treatment and reductionin pain, so images are not a good outcome measure.12
9. Don’t be worried about rupture.
Pain is protective as it causes unloading of a tendon. In fact most people who rupture a tendon have never had pain and do not present clinically, despite the tendon having substantial pathology.13
10. Don’t rush rehabilitation.
Tendon needs time to build its strength and capacity. So does the muscle, the kinetic chain and the brain. Although this can be a substantial time (3 months or more), the long-term outcomes are good if the correct rehabilitation is completed.14
The above 10 treatment approaches take valuable resources and focus away from the best treatment for tendon pain—exer- cise-based rehabilitation. A progressive programme that starts with a muscle strength programme and then progresses through to more spring-like exercises and including endurance aspects will load the tendon correctly and give the best long- term results.