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Hi, it is Tom here from Running Physio. Today I want to talk to you about some treatment options for hip dysplasia, including eight steps that you can follow to help you get great results for patients presenting with this condition.

As ever, I've also put a link to our running injury videos. We've got a great free series on shin pain. Also a great one on iliotibial band syndrome. So do check those out if you haven't done so already.

This is the third and final video in this series on hip dysplasia. So you may have seen the one that we did on identifying hip dysplasia and also on the different types. So do you have a watch or a listen to those if you haven't done so already.

I'm not an expert in hip dysplasia, I'm learning about this condition, and as I learn, I'm wanting to share my findings with you. So hopefully this should be useful, but also I want to point you towards people that know more where you can find out more information, particularly I want to point out an excellent book chapter in Hip and Knee Pain Disorders by Holly Soper-Doyle, Michael O'Brien, and also Benoy Mathew. This is an excellent chapter in this book that I've learned a lot from, and Holly in particular has been super, super helpful with sharing lots of great knowledge on this condition. So I'd recommend following Holly, she's on Twitter @hipdysplasiaPT, and she's also got a fantastic website that I've put up on the screen as well.

Now one thing that Holly said, which I think is a good point to start this off with, is that with hip dysplasia, understanding the anatomy is actually key to management. And then it's about how we adjust our rehab according to the patient's anatomy. Now, of course, we don't just treat anatomy, we treat people, but we do with these particular conditions with hip dysplasia, where we know there is instability, where we know the condition can place more stress on certain parts of the hip joint, knowing the anatomy's really important. So I'd recommend spending a few minutes after this video sitting down with a hip model, if you've got one, and just experimenting with some of those positions that are associated with instability, because I think it can really help cement things in your mind. So it's a good first point, really consider the anatomy through this.

Okay, so let's delve into some of these steps. Now, this isn't necessarily going to be the exact order you're going to follow for every patient, but this will give you a rough idea of some of the things that you may want to look at if you have a patient presenting with suspected hip dysplasia.

So step one, as with every patient, it's going to start with a thorough assessment of the patient's needs. The things you particularly want to focus on in this condition will be aggravating and easing factors. Are they telling you certain positions really bring on their symptoms? They feel pain, they feel instability. Those are often positions we are going to need to try and adapt to settle symptoms. Likewise, are there easing positions where they feel much more comfortable? Can we use those to settle things down? We want to think about the pain sources, both intraarticular sources, including the joint and labrum, but also extra articular, and we'll talk about that in a little while. There's often muscle and tendon involvement in these conditions too. We want to find out about how this is affecting this person, what their functional limitations are. Some will struggle even with walking. Others may have had to stop their sport. So that gives us an idea of what we need to help them with.

We want a good idea of goals and barriers to those goals plus, As part of assessing anatomy, we want to have a look at things like their pelvic, and hip position. Are they very retroverted? Do they like to rest in very anterior pelvic tilts, et cetera. And then we're going to go on to assess strength control, particularly provocative positions. Their range, which is often more. Because they're hypermobile in some cases. And also psychosocial factors, particularly beliefs around the condition. So this is with every patient, it's such an important first step. We can't ever have a recipe where we say just do A, B, and C and everyone will get better. It's gotta start with that initial patient assessment and then we can come up with a plan based on individual need.

Now step two then, I think is, is a good idea to arrange appropriate investigations. And from what I'm reading around this topic, it seems sensible to do these fairly early. It seems to take a long time for dysplasia to be diagnosed, several years in many cases. So as you suspect it, we want appropriate investigations fairly early. This might be just starting with an X-ray. This can help us to identify hip dysplasia and the severity and nature of it, but it tends to be a two-dimensional picture of a complex anatomical structure and set of structures.

So a CT can then provide a 3D perspective of this, hip anatomy and the areas of instability. In some patients, an MRI might actually be appropriate. Now you might think, for example, that diagnosis isn't clear. There might be suspicion of a high-risk stress fracture like femoral neck, in which case an MRI is considered the gold standard.

So you can help with differential diagnosis and also to assess the state of the soft tissues around and within the joint. So important to think about those investigations early on and they can shape management. For example, if it's a high risk stress fracture like a femoral neck stress fracture, it's often a period of up to eight weeks of non-weightbearing that's required to settle things down. So this is an area where investigations are often indicated and they may well shape management.

Step three then very important in this condition because it can create a lot of fear and concern for patients, is patient education and understanding. So help them understand the condition, explain the factors that contribute to pain and how they can modify them. That can put them in control. If they know certain positions are going to be very provocative and irritating, and you give them some idea how they can change those, it can really help them settle their symptoms. So it's important to do that. That's where these aggravating factors that we are discovering in our assessment are really important.

We want to discuss the role of muscle strength and postural position within this. Generally a stronger hip is going to be more stable and more comfortable, and then give them the time and opportunity to address their fears and concerns.

And I want to explore those in session one if possible. And then it may be that you want to explore potential onward referral. This is a complex condition that sometimes requires multidisciplinary team involvement, so you might discuss onward referral for nutritional advice, weight loss, or surgery in more severe cases, particularly those that haven't responded well to conservative treatment.

See, that would be our third step. Let's help the patient to understand the condition before we go on to look to manage it together. It's so hard if you are a patient, if you've been a patient yourself and you don't really understand what you're up against, it's very scary and daunting. So again, we want to get that in the early sessions where possible.

Step four. Is looking at reducing loading into those end of range or unstable positions. So here we want to look at considering the aggravating factors. They can be things like yoga for example, because people are taking the hip into provocative positions which irritate their symptoms. And you might have seen the opening image for this, where we had a hint, don't do this. And from the image you can see that someone's pushing someone into a deep hip extension position. Probably trying to get a really big hip flexor stretch. If you have anterior instability, this is going to be very provocative. You're pushing them into the exact position they're unstable in, so look at modifying yoga and static stretching, which can be pretty provocative and are often provocative for those coexisting conditions as well.

You might want to look at static postures, standing and sitting postures, potentially walking and running gait potentially as well. So hopefully our aggravating factors will point us towards what movements may we want to try and modify. This isn't about saying you're moving incorrectly or this is a faulty way of moving.

But it's saying perhaps we can change this to something that's a bit more comfortable and less provocative as part of settling down your pain. Now, we've talked previously in this series about the different types of instability you can have, global instability, anterior instability, or posterior instability.

Now hopefully, if we've identified, which it's most likely to be, that can then help us with our activity modification.

If you have someone where you suspect global instability around the hip, which is perhaps your more kind of traditional view of hip dysplasia, they may well have both anterior and posterior symptoms.

So these will have a mixture of anterior, posterior or lateral instability. So we need to be guided by their aggravating positions where there's pain or sensations of instability. And it may be that we need to test things, trying symptom modification tests during these aggravating tasks to see if they reduce those symptoms.

So if they can reduce pain or sensations of instability or mechanical symptoms as well. So this might be things like altering pelvic tilt, during a provocative task, so trying a slightly more anterior, posterior pelvic tilt, reducing hip flexion or extension or rotation positions, and seeing if that helps in terms of symptoms.

You may also ask them to try contracting their core muscles because that can create a bit more stability around the pelvis. And we are really seeing does this help you do your symptoms feel better when we're doing them? Also modifying hip abduction or adduction position. So you might come into a slightly more abducted position to create a wider base of support, for example. And as we said, with these instabilities in general, but certainly with global instabilities, prolonged static stretches at end range joint positions should generally be either adapted or avoided.

Quite a high percentage of people with hip dysplasia are hypermobile, so they're not necessarily people that you would want to recommend going off and doing lots of static stretches in end range positions anyway. But sometimes what happens if you are hypermobile, it puts you in a position where you can do things that use that flexibility. So you like yoga, you like gymnastics, you like those movements because you can do it, you've got the range. But the downside may be that provokes symptoms for you if you've got instability or dysplasia. So something to bear in mind.

With anterior instability, so these are often patients reporting anterior hip symptoms that are aggravated in positions of hip extension or rotation. We would want to reduce that hip extension and or external rotation, so we might shorten stride length in walking or running.

We might encourage a slightly more anterior pelvic tilt to help with that. So if you have patients that tend to adopt a more sway back posture in a posterior tilt, they're hanging on those hip flexors to some degree, looking at adjusting that posture slightly, bringing them into a more neutral or even slightly anterior pelvic tilt and less hip extension can be helpful. As we said, the anatomy matters here, so be mindful that femoral anteversion may also increase sensations of instability or pain. So again, it's going to be coming down to modifying those positions where the patient's actually reporting pain or instability and seeing what helps.

Now finally our third type was posterior instability. These can have both anterior and posterior symptoms which can then, lead you towards other differential diagnosis. But with posterior instability is more aggravated by hip flexion and or internal rotation. So things like deeper squats and lunges may be painful, so you may want to limit the range that they go into those positions based on symptoms.

A slightly more posterior pelvic tilt might help. So if you've got patients that have pain, perhaps if they're sitting with a very anterior pelvic tilt, so they're in some hip flexion, but they're sitting up really tall or they're getting pain in sit to stand as they tilt that pelvis forward.

You might want to look at changing those movements slightly to see if you can reduce symptoms. Even sometimes simple things like increasing the height of the chair so they're not in such a flexed position to start with. And again, think about the other anatomy. Femoral retroversion may increase sensations of instability in someone with a posterior instability, it's going to come down to listening to the patients.

Identifying those aggravating factors and then seeing what can we do to experiment and change these positions. Now, naturally, we know with most types of injury, whether it's joints, muscle or tendon or bone. If we are able to reduce aggravating factors, quite often the sensitivity settles and it's a really important part of helping people settle their pain and gain control of their condition.

The flip side of it is if we never try and modify or reduce those aggravating positions, it's so hard to settle symptoms down and the treatments we might choose to use it then get just short-term effects. So it's an important part of settling symptoms and putting people in control.

Okay, step five would be looking at improving strength. Now people with hip dysplasia can be weaker around the hip, so we want to start with our assessments and identify where are they weak. Now, this might be in large muscle groups like the quads, glutes, and hamstrings, and there's a bit of evidence supporting strengthening those.

It might be that we look at the deep hip rotators, sometimes known as the hip cuff like the rotator cuff of the shoulder, to strengthen those. There may be some benefits in improving control of anterior posterior pelvic tilts or contralateral pelvic drop and seeing does it actually help with symptoms? So we're testing on individual basis.

A couple of things to consider with your strength work is your weight-bearing exercise is perhaps more likely to recruit those deep hip stabilisers. So we may start in side-lying positions or non-weight bearing positions, perhaps initially using things like bridges or side-lying leg lifts, depending on the patient and their needs, but we want to progress into weightbearing positions when we can.

You may also consider the position you're doing it in. So you think we might be familiar with a fire hydrant exercise where patients tend to extend and abduct the hip to work the glutes. Now this position can be pretty provocative in anterior instability.

So we want to think about those positions we're going to get people working in, again, based on symptoms, but have a little bit of think about what's the best position to work someone in. Also, if you think about side-lying abduction as an exercise, we know there's quite good evidence that it can recruit glute med. But if people are tending to do it in a fairly extended hip position, again it's going to be pretty provocative potentially if they do have some anterior instability. So that's something for us to bear in mind. So we want to build our strength.

And then step six is to develop control and proprioception. Again, it's going to be based on functional requirements and symptoms, but we want to try and work on improving that joint position sense and control and thinking about those movements that are most likely again, to be linked to their symptoms. So is it around perhaps developing control of pelvic tilt, as we've talked about, or control of hip adduction, if that's provocative for them.

So maybe your runners that tend to come into quite adducted positions, can you cue them to ensure that the knees don't touch as they run? Maybe it's hip flexion or extension that's provocative. Can we change the movement pattern we see with that? And looking at global patterns or combinations of movements potentially?

So if you watch someone, for example, do a single leg squat, sometimes what you'll see, maybe if they're a bit restricted in ankle range, is they'll hit the end of range for the ankle and they'll start to move elsewhere. So they'll start to flex forward at the hip and maybe come into deeper hip flexion positions, which may well be provocative if they have that more posterior instability.

So a couple of examples here where you may want to improve control or modify the technique will be reducing stride length during walking and running. So you're reducing hip extension for anterior instability, or trying to get them to have a more upright squat to reduce hip flexion for posterior instability.

So you could do a gym ball squat, might be a nice alternative. So someone's got their back against the gym ball, they're nice and upright. The movement then for the squat becomes more about flexing the knees and less about flexing the hip. So it's a lot of ways to modify the movements whilst developing control in those positions that they struggle with.

Okay last couple of points.

So step seven, we want to manage the coexisting pathology. It's really common for hip dysplasia to present with other painful areas. So muscle tendon pain around the hips common. There's some research suggesting half of patients with hip dysplasia may have iliopsoas-related pain. A gluteal tendinopathy can be a source of symptoms too, as can lower back pain in people with hip dysplasia. So we want to work on addressing these and there's going to be quite a lot of crossover between how we manage, say, hip dysplasia and how we manage someone who's presenting with some coexisting gluteal tendinopathy or hip flexor tendinopathy.

So we are going to reduce things like the stretches because they tend to irritate the tendon if there's some tendon pathology and pain there. We're going to look at modifying provocative positions in general, like we've talked about. In trying to strengthen up the muscle and tendon to stimulate it to adapt. So we are going to look at trying to address those, but hopefully there's a fair amount of overlap with the management of hip dysplasia as well.

Okay. Finally on my list here, step eight, improve general health. Now for some patients, if they are overweight, if they have a high BMI, weight loss may actually help for them. So to help reduce the stress on the joint and improve their outcomes. So that can be something to discuss and consider onward referral for. We do want to encourage people to be active wherever we can, but at a level that doesn't lead to flare up in symptoms, isn't increasing their instability, sensations or leading to pain during walking or pinching or anything else like that around the joint.

Encourage activity and then look at building from a manageable level gradually to where they want to be. Sleep and recovery can be really important as well. Night pain can be problematic for patients with hip dysplasia, so again, we might look at modifying sleeping positions to help. This is a condition that can have a big impact on people's lives and what they're able to do. So it may be that some will benefit from seeking some support for their mental health.

Now, finally, hypermobility is common in hip dysplasia. And there are lots of potential causes for this, including things like Ehlers-Danlos syndromes. So keep a lookout for those bigger picture things really that we may be able to help people with. And in those more complex cases, that's where we really, will want to work within a multidisciplinary team condition.

So hopefully there's some ideas in there that I've been able to take from some of the research that I've found and also that excellent help I've had from Holly and that book chapter I mentioned at the start I would look into that.

Something else that Holly was keen to stress is there's not a lot of evidence in this area, so we are still lots for us to learn, and that changes take time, typically at least eight to 12 weeks of rehab is needed. There's also going to be some patients that won't necessarily improve as much as they'd like to with conservative management.

So we've talked mainly about how we might address it conservatively, but some may well benefit from surgery. That's a whole other topic that I'm not going to delve into today, but that's something to consider and it's why getting appropriate investigations and perhaps teaming up with an orthopedic surgeon who's experienced in this area can help, so the patient's got all their options available to them.

So that's a little bit of an overview of some of the treatment options available for hip dysplasia. If you'd like to learn more about running injuries, as I said, do check out those free video series we have, I've included a link for that. Thank you very much for listening again today. Take care. Bye for now.