On this episode of the #AskMikeReinold show we talk about some of tips for treating someone with hip osteoarthritis to try to avoid surgery. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 222: Treatment Tips for Hip Osteoarthritis
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Transcript
Mike Reinold:
Emma from Portland says, “Hey guys, I love your podcast and I’m really starting to look at you as some of my mentors.” That’s awesome. Thank you for that. “I look forward to listening to you on my way to work every day. I’m a new grad PT and I’ve recently come across a patient with a pretty severe case of hip osteoarthritis that doesn’t seem to be responding to anything that I do. X-rays show severe osteoarthritis.” I was going to ask that question, was there x-rays? She doesn’t say the age, but I guess we could talk about it if this is in a younger or an older person too. I think she’s big on Instagram, what are your top five exercises, soft tissue, manual therapy, or mobilizations that I can do for this pretty irritable hip OA patient?”
Mike Reinold:
I’ll let it slide if you guys have four or six, or something like that. Emma said she specifically wants five.
Lenny Macrina:
I’ve got one.
Mike Reinold:
We have a bilateral hip OA, that stinks. I wonder if there’s some dysplasia or something like that going on. Anyway, bilateral hip OA, severe via x-rays. Man, what’s the first thing you think of when they come to you. You got this person on your schedule this day. Who wants to start?
Lenny Macrina:
Send them to surgery. I’m done.
Mike Reinold:
I think that’s going to be our conclusion but I think you got right to the punchline. Everybody literally just stopped this podcast and went to last week’s.
Lenny Macrina:
I’m not trying to create a controversy.
Mike Reinold:
Dan, when you see that on your schedule, what’s the first thing you’re thinking? Okay, it sounds pretty bad, how do I figure it out if it’s bad and what to do? What are you thinking?
Dan Pope:
I guess the first thing that I was going say is that at least from what I’ve seen in terms of hip OA, the research is mixed in whether or not we have a pretty good effect on those folks. Then also the other thing is that total hip replacement has a pretty good outcome for most folks. I think that’s important for PTs to understand. I can’t tell you how many folks I’ve had that have been dealing with hip pain for a long period of time. Then they get the surgery and they’re like, “I can’t believe I waited so long.” Obviously, age is going to be a big one. You mentioned that. If they’re already an older individual, then I’m already thinking that that might be a way to go.
Dan Pope:
The other piece is what have they tried already? First and foremost this is not necessarily a realm, but weight loss is going to be an enormous one. In terms of body weight, if you’re losing some significant body fat mass, I think it’s something like 5% of your body weight, you have a significant change with symptoms. That’d be something to try. If you’re looking down that barrel, then I would say we’re trying to get this person moving in any way possible that’s not provoking their symptoms. Obviously, avoiding things like deep hip flexion, squatting positions, but it really depends on the individual. Some people hurt with terminal hip extension so something like walking might be bad for that person. I would just do a thorough evaluation, figure out what they like to do, figure out what they’re able to do, and then try to push more of the positive exercise.
Dan Pope:
If they aren’t making a change over the course of time, obviously you can try other things. Things like hyaluronic acid. Those have mixed support too, but the surgery is generally a decent thing to go with. Try some weight loss if you’re able to do that.
Dan Pope:
I just learned this recently, but apparently body mass index obviously has a big role with osteoarthritis. It’s one of the big correlates with people advanced with OA and having pain disability over the course of time. What’s interesting about having a high body mass index is usually you have a lot of fat that accompanies that. Fat messes up the cartilage homeostasis so if you have a lot of fat cells in your body, you don’t turn over cartilage as quickly. It hampers that process. Basically you’re going to have more wear and tear, not because you have necessarily more body weight, but because you have more fat and you don’t have that good turnover of cartilage. Try to get that person moving, try to get them to lose body fat, maybe refer them to a nutritionist and work together with that person. If that’s not working, I wouldn’t be fearful of sending back to the surgeon and say, “Hey, it might be worthwhile to get this hip replaced.”
Mike Reinold:
Makes sense. How about you, Dave? What do you think? Dave, I’d love to hear your thoughts, too, on maybe somebody that’s a little younger and more dynamic and not necessarily the older population.
Dave Tilley:
I’ll kind of weigh in one thought on what Dan was saying with what we’re thinking about now, which is the older population, someone who’s more advanced and then I’ll go that way. I think as people who are looking down, like Dan said, at the barrel of surgery down the road, sometimes it’s really hard for that person to plan that in their life. To get a hip replacement, you have a lot of things that have to go well in your life to have time, finances, resources. You have a couple of months where you’re really not able to do too much.
Dave Tilley:
Something that I’ve talked a lot with, especially the newer students that we have, is I think people underestimate, like Dan said, how different types of exercise are hip or knee dominant, or they can do certain types of exercise. I think people have this, exercise equals squatting equals running. A lot of people just think, “I need to just run more and do some more squats and that’s going to make me feel better.” But there’s a billion different types of variants of exercises that, sometimes, people are just maybe not educated on how they can do knee dominant or different types of exercises. Like Dan said, do a good eval, find out maybe the three or four things that work well for them and just try to focus on those things. I’ve had some people in my past career who did really well with just walking in a pool, was their version of getting their heart rate up. They had never thought about that as being something, especially for hip OA, to unweight some of the hip joints.
Dave Tilley:
Play with a lot of options there. Then I think on the younger, active population side, obviously this is where I’m more involved in, in terms of my regular clients, is these people typically have a lot osseus and conjugal things that are just the way they’re born. They have more shallow hip sockets, the angles of their crossover sign, what they’re called, they’re sometimes more concerning. These people typically need a surgery at some point to either restore that anatomy or to give them new anatomy that’s going to help them be more comfortable. For these people, typically a lot of this is education on the right dosage and addition by subtraction.
Dave Tilley:
I find so many people that don’t realize some of the things they’re doing, similarly to what we just talked about, are provocative. They’re squatting super, super deep because someone said they should do that because it’s just a good full range motion squat. There’s a benefit to that for strengthening but so many of the people we see, especially in the fitness, fitness or crossfit space, okay, unless you want to Olympic lift, there’s really no reason to do a super deep front squat. I fall into that camp. I can go very, very low and load that heavy and my hips start to get cranky if I’m not taking care of myself. What are your goals? What do you want to give [inaudible 00:07:36]? What’s your version of this? A lot of that stuff is just grunt work, just grunt work of hypertrophy of the smaller, deep hip stabilizers. We do that with the cuff quite a bit, hypertrophy of the guff, but the hip has just as many supportive muscles that need to be getting attention for that very lax, that younger osseous kind of client.
Mike Reinold:
Nice. That was great. What do you guys think? Lisa, Mike, any input on this on stuff you guys seen?
Mike Scaduto:
Yeah, I can go. I think part of the question was what kind of soft tissue techniques or joint mobilizations do we use or do we prefer? I think definitely working on the posterior and lateral hip structures. That’s the piriformis, the glutes, the deep hip external rotators, and then glute med and glute min. I think these structures tend to be sensitized or just uncomfortable for patients. Get in there, do some soft tissue, make the soft tissue potentially feel a little bit better. Maybe neuromodulate some of that tone, then work on some of those isolated strengthening exercises that Dave was talking about through hip manuals or with the band, then with some weight. I will do some joint mobilizations, whether it’s an axial distraction, maybe a lateral hip mob, something like that, where it can help decrease some of their pain, potentially. That would be my strategy from a manual therapy standpoint.
Mike Reinold:
That’s good input. I like that. Combining that with some of the exercise modifications with Dan and Dave, I think that’s good. What’s up Dave?
Dave Tilley:
I just want to agree with Mike because I think in my population, but especially in the ones that we’re talking about with Dan’s stuff, it’s very easy to under-train those structures and to get a very quick fatigue of those things that are stabilizing the hip joint, just like a cuff would. People typically are under doing hip thrusts and proper side plank clamshells side band walks, things of that nature.
Lenny Macrina:
They make a difference. They really do make a difference. I honestly think just getting moving, getting them confident in that movement and getting those muscles, I hate to say firing because muscles can’t just get extinguished, but get those muscles going.
Mike Scaduto:
Like dinosaurs.
Lenny Macrina:
Exactly. I think it’s huge for people to feel like they’re exercise and feel like they’re moving and they get so much more confident in how they feel.
Mike Reinold:
I like the concept Mike said, like a cranky joint, you’re going to have a lot of reflects of guarding and stuff like that. Any soft tissue you can do to help work on that and manual stuff, I think is helpful. That’s a good use of manual therapy for hip pain. Are you going to be able to do a randomized controlled trial to see if that helps? No, but if you made their day a little bit less painful today, and then they can maybe get some more exercise or some walking in or something like that, then I think we can help them achieve some of their other goals. What else? Anybody else have anything exciting, not necessarily [crosstalk 00:10:21].
Lenny Macrina:
I do want to add that listening to Scaduto talk, it reminds me of listening to Talk Radio back in the day when somebody would phone in.
Mike Scaduto:
Is it really that bad?
Lenny Macrina:
It sound like a phone cal.
Mike Reinold:
Hey, guys. Long time listener, first time caller. I just want to say the Red Sox stank this year. I’m sorry. Great stuff, I think, from the team here. The one thing that I thought of while you guys were talking, too, is funny is a lot of people ask me about our movement assessments that we do in our Champion Performance Program. They’ll say, “Can I do this on older people, even elderly people, people with severe OA?” We’re like, “Of course you can.” That’s the whole concept. You want to go through the basic fundamental movements that humans do and then just see what they can perform and then work within that. Try to help people work within that. If somebody has pain with squatting but they don’t have pain with stepping and hinging for example, then just don’t squat and step and hinge and still work on some of those other things.
Mike Reinold:
I don’t think the solution is to just sit on the couch, if that makes sense. Awesome. Another great question. Thank you so much, Emma from Oregon. Just kidding, Oregon. No, but Emma, great question. We appreciate that. I’m sure that’s actually something that a lot of our listeners probably deal with. Hopefully that’s good. Heck yeah. Are they going to maybe go back to the doctor and need something? That’s okay, but remember everything you’re doing right now is going to help them feel better after surgery, if they do need that. Keep a good optimistic mindset with that. Everything you’re doing is probably still going to be beneficial at some point in time.
Mike Reinold:
Another great question. Appreciate it. Again, head to mikereinold.com, click on that podcast link and you can ask us more questions. Be sure to rate and review us on iTunes and Spotify. We will keep doing this and see you on the next episode. Thanks so much.
