Why physical therapy and exercise does not help your hip pain

Ross A. Hauser, MD. Caring Medical Florida
Danielle R. Steilen-Matias, MMS, PA-C. Caring Medical Florida

Why physical therapy and exercise did not restore muscle strength in hip osteoarthritis patients and athletes

Patients are often very confused as to why a physical therapy program or exercise/activity program did not help their hip pain as much as they thought it would. Clinicians, doctors, and therapists are equally confused.

This is very typical of the patients we see. They have been to physical therapy for months and nothing seems to have improved. How can this be? Many of these patients have been listening and reading about “5 great exercises” to strengthen their hip or about “stretching and strengthening techniques,” to greater hip support. These people have been told that exercise will lead to greater pain relief and an increase in mobility. So why is it not working for them, when physical therapy and exercise is so beneficial to so many others?

In this article, we will discuss why exercise and physical therapy failed to restore muscle strength in hip osteoarthritis patients and athletes and how regenerative injection treatments to the tendons and ligaments of the hip may add needed strength resistance to make exercise and therapy more effective for you.

If you are reading this article, it is very likely that physical therapy did not or is not helping you. Now you are equally concerned that because of the PT failure to achieve results you are going to be escalated to a surgical candidate or have your pain management prescriptions increased in strength.

Four months of physiotherapist-supervised, progressive, moderate, and strength training was less effective than thought for improving muscle strength and power in patients with hip osteoarthritis

Doctors at the University of Copenhagen published a study in the October 2017 edition of Physiotherapy Research International (1) in which they examined patients with hip osteoarthritis. Among the symptoms that these patients exhibited were noted impairments in muscle function (muscle strength and power) and hip range of motion.

So they set about to compare the short- and long-term effects of 4 months of three different types of therapy / exercise:

  • physiotherapist-supervised strength training,
  • physiotherapist-supervised Nordic Walking,
  • or unsupervised home-based exercise

They also explored the impact of each on muscle function and hip range of motion in patients diagnosed with hip osteoarthritis BUT NOT waiting for hip replacement. So this is a group of patients whose degenerative hip disease did not advance far enough yet for a hip replacement or people declining the suggestion to get a hip replacement.

Four months of physiotherapist-supervised, progressive, moderate, and strength training was less effective than thought for improving muscle strength and power in patients with hip osteoarthritis

The results were somewhat surprising, the treatments did not show any significant between-group differences for improvements in muscle strength and power or hip range of motion at any time points.

The researchers had to conclude:

  • Four months of physiotherapist-supervised, progressive, moderate, and strength training was less effective than thought for improving muscle strength and power in patients with hip osteoarthritis who are not awaiting hip replacement. Our results may indicate that in these patients, improvements in disability are not necessarily dependent on improvements in strength and power or hip range of motion.

So what the researchers were suggesting was the supervised physical therapy for strength training was not helpful. But the walking, and whatever exercise the patient themselves came up with was.

  • Here is a clue that it was not the physical therapy strength training that was ineffective, but rather, weakened damaged ligaments and tendons in the hip that failed to provide enough resistance to make muscles stronger.

What does all this mean? Muscle strength and power are problems that clearly need to be addressed to reduce pain and disability in hip osteoarthritis.

Loss of strength, muscle power, and range of motion are clear indicators of an impending hip replacement. In patients with degenerative hip disease, where connective tissue such as the tendons that attach hip muscles to the bones are damaged. It is very difficult to derive benefit from strength training where resistance is needed because the tendons that help provide that resistance are weak.

People were giving up on the exercise because it was not helping and they did not have the strength to do it.

Here is another clue that your damaged tendons and ligaments are the problem. A team of researchers from Oslo University in Norway evaluated the long-term effect of exercise therapy and patient education on range of motion, muscle strength, physical fitness, walking capacity, and pain during walking in people with hip osteoarthritis. In the above study from the University of Copenhagen, we found that walking was beneficial and the patient’s own home exercise derive program was beneficial. Strength training was not. It should also be pointed out that in the above study, people were not waiting for hip replacement.

Published in the journal Physical Therapy, (2) the key to this Oslo University study was focus on walking as the exercise. Six minutes of walking every day. What the researchers found was no improved range of motion, muscle strength, or how much distance during the 6-minute walk the patient could cover. Another factor the researchers noted was 53% rate of adherence to the exercise therapy program. People were giving up. Why were they giving up? Because many participants had already planned to get the total hip replacement. 

The more hip osteoarthritis – the weaker the muscles – the more inability to do exercise – Are you too far gone?

We are going to listen now to doctors at Griffith University in Australia who will tell us about hip osteoarthritis patients with weakened muscles. This research appears in the medical journal BioMed Central musculoskeletal disorders (3). Basically, they looked at people, probably just like you, people with advanced hip osteoarthritis who have generalized muscle weakness of the affected side from leg to toe.

Learning points

  • While people with hip osteoarthritis are recommended to strength training exercises and therapy the extent and pattern of muscle weakness, including any between-limb asymmetries (possible leg length discrepancies, more muscle in one limb than the other causing problems related to a lack of symmetry) in the early stages of the disease are unclear.
    • In other words – there is a question as to the impact physical therapy and exercise will have if you are “tilted,” or unbalanced.
  • Nineteen (19) people with mild-to-moderate symptomatic (it hurts) and radiographic hip (the MRI is showing hip degenerative problems).
    • 12 people had one hip problem
    • 7 people had problems in both hips.

What they found:

People with hip osteoarthritis demonstrated significantly lower:

  • Knee flexor and knee extensor range of motion. (Your ability to bend your knee to normal ranges)
  • Hip flexor and  hip extensor range of motion (Your ability to bring your knee towards your chest) and hip abductor strength (Your ability to move your hip rotationally).
  • Atrophy, bilateral hip and knee muscle weakness is commonly found in people with mild-to-moderate hip osteoarthritis. Early interventions to target muscle weakness and prevent the development of strength asymmetries that are characteristic of advanced hip osteoarthritis. appear warranted.

Research: We know the hip ligaments are important, they may be more important than we think in helping restore muscle strength.

Throughout this article, we discuss the loss of muscle strength and the inability of people to benefit from physical therapy for their hip pain. We also suggest that physical therapy results can be improved if you strengthen and repair weakened and damaged tendon attachments. The tendon’s enthesis is that piece of tissue that attaches your muscle to the bone.  The term enthesopathy typically refers to a degenerated enthesis and this may have been discussed with you at one of your many doctor or PT visits.

We are going to discuss tendons and muscles below. But let’s stop here for a moment to discuss the hip ligaments. The hip ligaments are the strong connective tissue that hold your pelvis, hip, thigh bones, sacrum, lumbar vertebrae all in place. The bones do not go wandering off on their own because the ligaments keep them in line.

When these ligaments are damaged because of degenerative wear and tear, the bones do wander off and start floating around. They start to bang against each other in unnatural damaging contact.

When you first go to a doctor with hip pain, it is rare for the doctor to acknowledge that your problem may be from the ligaments. The reason? Ligaments are not cartilage and they are not bone. It is easier to describe to someone that they have a “bone on bone” than try to describe a ligament problem.

Your physical therapy is not working because your muscles are not getting sufficient resistance because of weakened and damaged tendon attachments.

Doctors not knowing or understanding the hip ligaments and their role in hip stability are slowly recognizing ligaments as a major problem in the treatment of hip pain. Listen to what a team of German surgeons at the Department of Orthopedics at the University of Leipzig has recently published in the health journal PLusOne.(3)

  • We know that hip ligaments contribute to hip stability.
  • We do not know how ligament damage affects men and women differently or how ligaments affect inside, outside, front or back hip pain.
  • We do not know clearly know how ligaments interact with other tissues stabilizing the pelvis and hip joint, as research is scant.

Here is the concluding statement of the paper abstract:

  • “Comparison of the mechanical data of the hip joint ligaments indicates that their role may likely exceed a function as a mechanical stabilizer.”

Your physical therapy is not working because your muscles are not getting sufficient resistance because of weakened and damaged tendon attachments. The tendon attachments are weakened because the bone they are attached to maybe floating around overstretching that attachment. The bone is floating around because of weakened and damaged ligaments.

Back to the muscles: There is limited evidence that physical therapy helps patients with hip osteoarthritis and we think it may be the gluteus minimus muscle

Researchers in Australia and New Zealand are embarking on a new study. They hope to be able to answer the question as to why physical therapy is not helping many patients.

Here are the learning points of what this pending research is trying to do published in the clinical journal Trials (4):

  • Clinical practice guidelines recommend exercise as the first line of management for hip osteoarthritis, yet high-quality evidence suggest only slight benefits for pain and physical function; and no benefit on quality of life.
  • However, the scope of physical impairments identified in people with hip osteoarthritis may not have been adequately addressed. (In other words, the therapy did not match the specific challenges the patients were facing. People with significant hip osteoarthritis may have been offered similar treatments to patients with mild osteoarthritis).
  • More success may come with targeted options include gait retraining to address impairments in walking; motor control training to address deep gluteal (gluteus minimus) dysfunction; and progressive, high-intensity resistance exercises to address atrophy of the gluteal muscles.
  • The aim of this study is to investigate the effect of a targeted gluteal rehabilitation program that incorporates gait retraining, motor control and progressive, high-intensity resistance-strength training, to address physical activity levels and self-reported physical function in people with mild to moderate disability from hip osteoarthritis.

What this study is doing is focusing on the gluteus minimus muscle dysfunction. The goal of the study is to show that if you make this muscle stronger, you can eliminate a lot of pain in hip osteoarthritis patients and improve mobility and function.

We agree it is the gluteus minimus muscle when there is gluteus medius tendinopathy

The inability to benefit from strength training is a clear sign of total hip joint degeneration

It is difficult to isolate one part of the pelvic-hip-spin complex when treating a patient with problems of Gluteus Medius tendinopathy.

The constant strain on the muscles to produce strength and stability in the hip is actually causing more degenerative problems because of tendon destruction.

In our article Gluteus Medius tendinopathy, we discuss how

  • The traditional and conservative care treatments of Gluteus Medius Tendinopathy are not helping people
  • Getting to the evidence: Does Gluteus Medius tendinopathy treatments makes your hip, lower back, knee, and ankle hurt and hurt worse?
  • Treatments for Gluteus Medius Tendinopathy to improve physical therapy and alleviate pain.

Prolotherapy more effective for patients who developed osteoarthritis as a result of developmental dysplasia of the hip than surgery or exercise

In this article, we make the case that without strong ligament and tendon attachments, there is not sufficient resistance to allow the muscles to strengthen. In our clinic, we address this problem with the use of Prolotherapy.

Prolotherapy is the injection of simple dextrose, sugar, which calls native repair cells to the areas of damaged soft tissue. Specifically the tendon and ligament attachments.

A February 2020 study comes to us from orthopedic surgeons operating in Turkey, specifically the Department of Orthopedics Surgery at Tokat State Hospital and the Department of Sports Medicine, Health Sciences University Gulhane Medical Faculty, Ankara, Turkey. The study was published in the journal Medical Science Monitor.(5)

In this study, the research team looked at patients who developed osteoarthritis as a result of developmental dysplasia of the hip, (the socket of the hip joint being too shallow). This is a major cause of hip pain and disability.

According to the researchers, “the aim of the study was to compare the effectiveness of prolotherapy injections versus exercise protocol for the treatment of developmental dysplasia of the hip.”

  • There were 46 hips of 41 patients who had osteoarthritis secondary to developmental dysplasia of the hip included in this study.
  • Patients were divided into 2 groups:
    • 20 treated with prolotherapy and
    • 21 treated with exercise.
    • Clinical outcomes were evaluated with a visual analog scale for pain (VAS) and Harris hip score (HHS) at baseline, 3 weeks, 3 months, 6 months, and a minimum of 1-year follow-up.
  • At the start of the study, no differences in pain and function were noted. Then treatments began.
  • Dextrose Prolotherapy injection recipients outperformed exercise controls for VAS pain change score at 6 months and 12 months and for HHS function scores at 6 months and 12 months.

The study concluded: “To our best knowledge, this study is the first regarding the effects of an injection method in the treatment of osteoarthritis secondary to developmental dysplasia of the hip. According to our study, Prolotherapy is superior to exercises. Prolotherapy could provide significant improvement for clinical outcomes in developmental dysplasia of the hip and might delay surgery.

In this video, Ross Hauser, MD demonstrates and describes the Prolotherapy treatment. A summary transcription is below the video.

  • This is a hip procedure on a runner who has hip instability and a lot of clicking and popping in the front of the hip.
  • This patient has a suspected labral tear and ligament injury.
  • The injections are treating the anterior part of the hip which includes the hip labrum and the Greater Trochanter area, the interior portion, the gluteus minimus is treated.
  • The Greater Trochanter area is where various attachments of the ligaments and muscle tendons converge, including the gluteus medius.
  • From the front of the hip (1:05) we can treat the pubofemoral ligament and the iliofemoral ligaments
  • From the here posterior approach I’m going to inject some proliferant within the hip joint itself and then, of course, we’re going to do all the attachments in the posterior part of the hip and that will include the ischiofemoral ligament, the iliofemoral ligaments. We can also get the attachments of the smaller muscles  you’re obviously going to get some of the smaller muscles too including the Obturator, the Piriformis attachments onto the Greater Trochanter
  • Hip problems are ubiquitous, the hip ligament injury or hip instability is a cause of degenerative hip disease and it’s the reason why people have to get to get hip replacements.

Do you have questions about making physical therapy work better for you? You can get help and information from our Caring Medical staff.

1 Bieler T, Siersma V, Magnusson SP, Kjaer M, Beyer N. Exercise induced effects on muscle function and range of motion in patients with hip osteoarthritis. Physiotherapy Research International. 2017 Oct 3. [Google Scholar]
2 Svege I, Fernandes L, Nordsletten L, Holm I, Risberg MA. Long-term effect of exercise therapy and patient education on impairments and activity limitations in people with hip osteoarthritis: Secondary outcome analysis of a randomized clinical trial. Physical therapy. 2016 Jun 1;96(6):818-27. [Google Scholar]
3 Loureiro A, Constantinou M, Diamond LE, Beck B, Barrett R. Individuals with mild-to-moderate hip osteoarthritis have lower limb muscle strength and volume deficits. BMC Musculoskelet Disord. 2018;19(1):303. Published 2018 Aug 21. doi:10.1186/s12891-018-2230-4 [Google Scholar]
4 Van Arkel RJ, Amis AA, Jeffers JRT. The envelope of passive motion allowed by the capsular ligaments of the hip. Journal of Biomechanics. 2015;48(14):3803-3809. [Google Scholar]
5 Semciw AI, Pizzari T, Woodley S, Zacharias A, Kingsley M, Green RA. Targeted gluteal exercise versus sham exercise on self-reported physical function for people with hip osteoarthritis (the GHOst trial–Gluteal exercise for Hip Osteoarthritis): a protocol for a randomised clinical trial. Trials. 2018 Dec;19(1):511. [Google Scholar]
6 Gül D, Orsçelik A, Akpancar S. Treatment of Osteoarthritis Secondary to Developmental Dysplasia of the Hip with Prolotherapy Injection versus a Supervised Progressive Exercise Control. Med Sci Monit. 2020;26:e919166. Published 2020 Feb 11. doi:10.12659/MSM.919166 [Google Scholar]


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