Why physical therapy and exercise did not work for your hip osteoarthritis or tendinopathy pain
Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
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. In this article we will discuss why exercise and physical therapy failed to restore muscle strength in hip osteoarthritis patients and athletes and how 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 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
This is very typical of patients we see. They have been to physical therapy for months and nothing seems to have improved. How can this be?
Doctors at the University of Copenhagen published their 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 physiotherapist-supervised strength training, physiotherapist-supervised Nordic Walking, or unsupervised home-based exercise on muscle function and hip range of motion in patients diagnosed 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.
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 clearly 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
This was not the only study to acknowledge that the benefits of exercise maybe limited in people with hip osteoarthritis.
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.
Published in the journal Physical Therapy, (2) the key to this study was the 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.
New research study: 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 (3):
- 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 osteaorthritis patients and improve mobility and function.
We agree it is the gluteus minimus muscle when there is gluteus medius tendinopathy
Inability of benefit from strength training is a clear sign of total hip joint degeneration
It is difficult to isolate on one part of the pelvic-hip-spin complex when treating a patient with problems of Gluteus Medius tendinopathy.
- When the hip joint region becomes unstable, the muscles, including the Gluteus Medius, tries to create stability by tensing. As is the case with any joint of the body, ligament and tendon instability initiates muscle tension in an attempt to stabilize the joint.
- This compensatory mechanism to stabilize the hip joint eventually causes the gluteus medius, piriformis muscle, and iliotibial band/ tensor fascia lata muscles to tighten because of chronic contraction in an attempt to compensate for hip joint instability. The contracted gluteus medius can eventually irritate the trochanteric bursa, causing a trochanteric bursitis.
The constant strain on the muscles to produce strength and stability in the hip are 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.
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 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]