Conditions & Injuries: Hips & Thighs

Iliotibial band (ITB) syndrome

Iliotibial band syndrome typically presents as a sharp pain on the outside of your knee when your heel strikes the ground, but it also can radiate into the outer thigh or calf. The pain is worse when you run or walk down stairs.

The iliotibial band is the band of connective tissue that runs from the outside your hip down the side of your leg to the lateral side (outside) of your knee. When it is overworked or overly tight it can cause irritation and pain on the side of the knee.

Common causes

ITB syndrome isan over-use injury typically seen in runners and is often caused by weak hip abductor muscles, which result in the leg being leg turning inward from the hip. This puts extra tension on the ITB, which causes irritation where the band attaches to the bottom of the femur (thighbone). Cycling with your feet turned inwards can also cause ITB syndrome.

How we treat ITB syndrome

Physiotherapy is the main treatment for ITB syndrome. Initially, you can use ice or heat to help relieve the pain and manage it during your recovery, but we’ll advise you to stop running while the symptoms are painful.

Therapy can include soft tissue massage to release tightness in the muscles that feed into your iliotibial band, which include your gluteus medius, gluteus minimus and tensor fasciae latae (TFL). The ITB itself can’t be stretched as it is a thickening of fascia that surrounds the muscle belly of your thigh.

As the main contributor to ITB syndrome is weakness in your hip abductors, this will be the main movement and muscle group that we will aim to strengthen with a programme providing progressive load. We will also look at motor control around the hip and address any other weaknesses to ensure that the ITB is not continuously loaded through your thigh being adducted (pulled inward). We will use video imaging to assess your running gait pattern and provide you with cues and advice on how to adapt this to avoid the iliotibial band pain returning and ensure you can return to running with no problems. Other treatments could include shockwave therapy and muscle stimulation to activate your hip abductors.

Average recovery time

Depending on the severity and how long you’ve had the ITB syndrome it can take 6 weeks to a year to fully recover.

Anterior thigh pain

Pain in the front of your thigh is usually due to straining your quadriceps, but there are other possible causes. Anterior thigh pain can be caused by a quadriceps contusion when you have a direct blow to the thigh, compartment syndrome of the thigh (which is when there is bleeding within the muscle belly), a strain at the top of rectus femoris, the quadricep muscle that goes across the front of your hip and attaches to the ilium of your pelvis, or a stress fracture in your femur (thighbone). A physiotherapist or doctor should be able to identify the cause of your thigh pain.

Common causes

You may strain your quadricepswhen you try to straighten your knee under a heavy load that your quads are unable to manage, for example during a heavy squat. Or if you’re trying to keep your knee straight when a force is pushing down on the lower half of your leg.

How we treat strained quads

If you have compartment syndrome or a stress fracture, the physiotherapist will refer you for further investigation as these could require surgery.

For the other causes of anterior thigh pain, physiotherapy will initially consist of a combination of soft tissue release to aid with reducing muscle tightness, reduce swelling and potential bruising, and help you to regain full mobility of the hip and the knee. We’ll provide you with a strengthening programme starting with low resistance and high repetitions and then slowly increasing the load through the leg to the required strength needed for everyday activities and sporting activities.

Once you’re pain free and have regained your full mobility, we will assess your movement control and general strength in your trunk and lower limbs to see whether compensating for a weakness could’ve caused the overloading of your quadriceps. We'll also look at your gait pattern to ensure that you go back to walking and running with a normal gait and don’t overload your non-injured side.

Average recovery time

Depending on the injury and what other intervention is required outside of physiotherapy, it can take 6 weeks to 6 months to make a full recovery.

Hamstring pain

Pain in the hamstrings is usually due to either a strain or tear of the hamstring tendons or muscles. This can be either in the upper, middle or lower portion of your hamstrings. You may hear a popping sensation when you initially injure the hamstring. You will have tenderness over that area, pain when you move and swelling around the injured area. Depending on the grade of the strain or tear, you may lose some of the strength within your hamstring which will affect your ability to move your leg backwards from the hip or bend your knee.

If a tendon tear is not dealt with correctly it can result in a tendinopathy (inflammation of the tendon). Hamstring tendinopathies can also be caused by repetitive leg motions, like those involved in running or cycling. Typically, the pain from a tendinopathy will get worse when you’re bending forwards from your waist or trying to speed up your movements.

Common causes

Hamstring strains and tears are normally due to sudden movements such as sprinting, lunging beyond your capacity to control the movement, or jumping.

How we treat hamstring pain

Most of the time hamstring strains can be treated with physiotherapy. But if you have had a complete tendon tear you may need surgery to reattach the hamstring.

We would perform soft tissue release of the hamstring to help you regain mobility in the back of your thigh and help reduce bruising and swelling. Typically, you don't want to stretch the hamstring during the first two weeks after injury to avoid irritating or enlarging the tear or strain. It depends if you have a proximal (closer to the hip) or distal (closer to the knee) injury as to the type of strengthening exercises you will be given. Certain strengthening exercises can aggravate the injury if it is proximal, and we would also advise avoiding bending forward at the hips as this can irritate the tendon more. For distal strains or tears, you should avoid any rotational movement at the knee.

After a thorough assessment of your range of movement in the hip and knee and your muscular strength and control of the leg, we’ll provide you with a strengthening programme that will progressively load the hamstring and address other areas of weakness to ensure that you don't overload your hamstring when you return to normal and sporting activities. We’ll also assess your gait pattern to ensure that it is balanced and won’t cause further problems.

Average recovery time

Depending on the severity of the hamstring injury, it can take between 6 weeks and 6 months to fully return to normal activity and sporting activity.

Hip pain

Hip pain can have many causes and present in many ways. If you have pain in the front of your hip it could be due to impingement or to having tight or weak hip flexor muscles. Posterior hip pain could be due to a gluteal tendinopathy, while pain on the side of your hip could be caused by iliotibial band (ITB) syndrome, gluteal medius tendinopathy, trochanteric bursitis or impingement.

Common causes

Common causes of these problems are muscular weaknesses which result in poor control of your legs or leg, or a sudden increase in load on the muscles due to an increase in the intensity or time you are training. Impingements can be caused by either a genetic abnormality in your hip joint, or a bony change in the hip joint because of altered movement patterns or the load that you're putting through the joint.

How we treat hip pain

If it is a muscular cause, this can be usually be treated with physiotherapy alone. Treatment will involve identifying the weak areas and providing you with a progressive loading programme to build them up to the loading levels required by your chosen activities. We will assess your movement patterns in a controlled environment and in the activity that possibly caused your pain. We’ll then provide you with a sport-specific programme to improve the movement patterns and also a graded exposure to this activity.

Other treatments such as shockwave therapy and steroid injections may be used alongside physiotherapy. Pain caused by impingement may require surgery to get rid of the joint abnormalities, but this will depend on the extent of the change in the joint surfaces. Following surgery your physio will work with you to regain a full range of movement in the hip and build back your strength.

Average recovery time

Recovery time from hip pain can range from 6 weeks to a year, depending on how long you’ve had the condition and whether surgery is required.

Hip arthroscopy

When performing a hip arthroscopy a surgeon will make two small incisions around the hip joint and insert a camera and tools to either assist with diagnosing a hip-related problem and/or treat a hip problem.

Common causes

Typical hip conditions that will be repaired by a hip arthroscopy are labral tears and cam or pincer conditions and femoroacetabular impingement (FAI).

Rehabilitation after a hip arthroscopy

After a hip arthroscopy, your physiotherapy will include manual therapy of soft tissue release, lymphatic drainage, and mobilisation of the hip to regain full range of movement and assist with bruising and swelling reduction. We’ll then assess your muscular strength around the hip and adjacent joints, movement control and gait pattern. This will help determine the exercise programme that is required to make a full recovery.

Depending on the surgery, the surgeon may want you to non-weight-bearing to start with, progressing to full weight-bearing. In this case we may use hydrotherapy as part of your treatment to enable you to regain full mobility in the hip and initiate strengthening and gait re-education while you are still partially weight-bearing. Once you are able to put your full weight on the leg, your exercise programme will be land based with progressive loading of the hip and the surrounding soft tissues that support the joint.

Average recovery time

The recovery time depends on what caused the need for the hip arthroscopy. It can vary between 6 weeks and a year to make a full recovery and get back to your full range of normal activities, depending on what those activities are.

Read our article on Preparing for your hip surgery

Total hip replacement

A total hip replacement surgery involves the replacement of the head of your femur (thighbone) and the acetabular (your hip joint socket) with an artificial joint. Typically, people who need a total hip replacement feel pain radiating from their hip joint down to their knee when they have this type of damage in the joint, and in some cases people may only get referred pain into their knee.

Common causes

A total hip replacement becomes necessary when changes to the joint surfaces result in joint pain and reduce mobility in your hip.

Rehabilitation after a total hip replacement

After the operation, you will start physiotherapy straightaway in the hospital and then continue either at home or in a clinic. Exercises will initially be focused on improving your range of movement and activating the muscles around the hip. As you improve, exercises will be tailored for the activities you want to return to doing.

Your treatment will also include wound care and soft tissue release to aid with muscular tightness, swelling and bruising. You will initially start walking with a Zimmer frame and then progress quite quickly to crutches. Typically you will leave hospital using two elbow crutches and will the progress to walking unaided. At this point, we’ll look at your gait pattern to make sure you don't return to the adaptive walking gait that you would have used prior to the operation, making sure you’re bearing your weight evenly through both legs with good alignment.

Hydrotherapy may be used to aid with your recovery, especially if it’s uncomfortable to fully weight-bear through the leg. Water-based exercise will include range-of-movement exercises and gait re-education, as well as using the resistance of the water to initiate muscle strengthening in the leg.

Initially you will need to avoid forcing your hip to bend or rotate, but we’ll encourage you to move within the range that is comfortable. Typically, hip abduction (taking the leg out to the side) is the most difficult to perform after this surgery because of the location of the incision that is made to access the hip joint during the surgery, so these movements will be key in your rehab programme.

Average recovery time

It will typically take you about 6 months to return to all your normal activities at the same level as prior to the hip problems. But this will depend on how much your muscle has deteriorated, and also on what those activities are. Sporting activities normally take slightly longer due to the control required around the hip. Most people will be able to walk unaided between 2 to 6 weeks after the surgery, and at 3 months they can start returning to sporting activities.

Read our article on Preparing for your hip replacement

Groin pain

Groin pain can be caused by a muscle, tendon or ligament strain or sprains, and is particularly prevalent in hockey, football or rugby players. It’s often due to an injury or tear in your hip adductors, which are the muscles on the inside of your thigh. This injury will typically happen during kicking, twisting to change direction, or jumping. Typical symptoms are swelling and bruising on the inner thigh, stiffness, weakness, numbness, spasm, tingling and cramps in the region of injury.

Common causes

Besides being caused by muscle, tendon or ligament strains or sprains, groin pain can have many other causes. In women, groin pain can be an indication of an enlarged lymph node, a femoral hernia, a stress fracture in the hip, an inguinal hernia, kidney stones, osteitis pubis, ovarian cysts or a nerve entrapment. In men it can be nerve related or testicular in origin.

How we treat groin pain

If the groin pain is caused by a strain or sprain, physiotherapy treatment will include manual therapy to release muscular tightness and relieve swelling. We will also provide strengthening exercises for your hip adductors with progressive loading as the muscle heals. We’ll also assess other muscle groups that support the action that caused your muscle strain and give you exercises to improve their strength. Then we will look at the control you have in the action that caused the strain to ensure that you are performing this optimally and provide guidance on how control could be improved.

Average recovery time

The severity of the muscle strain will determine how long it will take to recover. If it's a grade 1 strain, you should be able to return to normal activities within 6 to 12 weeks. If there's a grade 3 strain, which is a complete rupture, then you may need surgery and likely to return fully to normal activity within a year.

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