Hip and Shoulder Pain: May be Related

     This little schematic is a good reminder to me of how the body works sometimes. The hips and shoulders tend to work opposite (and affect each other opposite) like when the left shoulder hurts that can cause the right hip to hurt. When you swing the right hand forward (connected to the shoulder) it is the same time as the left hip and leg are going forward. Equal and opposite. This is normal mechanics with one affecting the other. Tightness in the left shoulder can cause tightness and pain to start developing in the right hip and low back. 

     When the symptoms always appear on the same side, say right hip and right shoulder, as a podiatrist I am looking at structural or functional leg length differences. 

Sunday's Video of the Week: Piriformis Syndrome Stretches combined with Neural Flossing

Piriformis syndrome is quite common in the athletes our Sports Center treat. I have another few posts on this syndrome. Since the piriformis muscle/tendon is an external rotator of the hip, and since excessive foot pronation can cause excessive internal rotation of the hip, podiatrists are called on to design orthotic devices to correct that. If the hip internally rotates too much, the external hip rotators must overwork to stabilize the hip, and the piriformis may strain, swelling, tighten and irritate the sciatic nerve. Here is a wonderful video on combining piriformis stretching with neural flossing (see my other posts on neural flossing). Do these gently at first to see if they have any negative reaction. Or, review with your physical therapist on some modification that is tailored to you. But, sufferers of piriformis syndrome will be helped with some version of these wonderful exercises. Good luck! As you can tell from another post on neural flossing, I personally prefer spine neutral stretches with the patient laying on the back.






Also check out this incredible video about the San Francisco Fog!!

http://biggeekdad.com/2014/02/san-francisco-fog/#.UvgAty4zOhQ.gmail

Basics of Gait Evaluation: Hips



When watching someone walk and/or run  (also known as gait evaluation), it is important to look at what the hips are doing. The hips are a reflection of shoulder motion (right shoulder and left hip), intrinsic hip and low back conditions, and  foot motion (or lack of). The green circle reflects normal hip motion and symmetrical right to left hip heights. The light purple circles represent some of the more common conditions seen. I am always asking if the hip evaluation represents shoulder abnormality, hip and/or low back abnormalities (including scoliosis and pelvic asymmetries), or foot and knee rotations. It is exciting to try to put the patterns together and make some sense out of them.

I remember one of my first race-walkers that I treated. Maryann had right hip pain with a long left leg, excessive foot pronation, exaggerated hip motion even in normal walking, and very tight ilio-tibial bands. As I co-treated her with a physical therapist, we successfully leveled the hips, stopped the excessive pronation, and stretched out the IT Bands. Yet, her hip pain was just as bad. A low back consultation felt that her pain did not come from the back, and the physical therapist did not feel that it was referred pain from her knee. Finally, I went to the track for one of her race walking training sessions. As I watched her walk, I realized and her coach, she did not move her left shoulder (or her right shoulder for that  matter). The hips should move equal and opposite to the shoulders (right hip and left shoulder) for maximal efficiency and ease of motion. The solution to Maryann's problem and then many years of painfree race walking was to get her to move her shoulders freely.

The checklist of hip gait evaluation observations is:

• Symmetrical Hip Heights and Motion
• Low Back Issues

1. Lordosis
2. Flat Back
3. Scoliosis

• Hip Motion Symmetry
• Hip Height Difference

1. Right Higher
2. Left Higher

• Trendelenberg (Hip Drop)

1. Drop to Right
2. Drop to Left

• Hip Hike

1. To Right
2. To Left

• Excessive Hip Motion

1. Forward to Right
2. Forward to Left
3. Out to Right
4. Out to Left
5. Transverse Plane
6. Sagittal Plane
7. Frontal Plane

• Limited Hip Motion



Hip Pain Decision Making: Role of Bone Scan

Here is the one of the hip xrays from my patient Albert. Albert has degenerative changes (wear and tear) on both hips, right greater than left. This is a standing AP Pelvic Xray with shoes on showing a short right leg that I am using lifts to level. Albert has had 6 synthetic cartilage injections into both hips, with the left hip doing great and the right hip still in pain. What complicates matters and the decision making for hip replacement is that he also problems with his right sacro-iliac joint and his right lumbar spine. Both areas can produce pain that can mimic hip pain and vice versa.

Here is a magnified image of Albert's right hip. The degenerative changes are mild to moderate only. Should he have a hip replacement was the question he asked me? I have seen Albert's function diminish over the last year and now he always has a cane in his left hand. But the xrays didn't look that bad!! His orthopedist was conservative, and really good at telling Albert that he would know when he needed a hip replacement. But was it just referred pain from the SI joint or low back? I encouraged him to get a bone scan for more definitive answers. He approached his orthopedist on the subject and the test was ordered.

Here is the Tc 99 bone scan images of Albert's hip area. I apologize that the image is turned around, but the side of the intense dye uptake is in the right hip. Bone scans document bone metabolism. Where is Albert trying to mend at the bone layer? The Tc 99 dye glues itself to the phosphorus molecules in your body. Phosphorus, calcium and water make up bone. After 2 hours of letting the dye circulate, the images are collected.

Here is a higher image on the body showing the dye in the kidneys already. You urinate the dye out of your body over 12 hours and patients are encouraged to drink alot the day of the test. The lumbar spine looks normal, but there is a slight increase in the right SI joint. But the dye accummulation in the right hip is so intense, Albert will be scheduling a hip replacement soon. Hopefully, we can get his short right leg corrected at the same time.

Iliotibial Band Tendinitis: 3 Common Stretches

The above video demonstrates the 3 common iliotibial band stretches I show patients suffering from this common running injury. It is almost rare in other sports, since it is a repetitive stress syndrome where the ilio tibial band rubs over either the greater trochanter of the femur at the hip or the lateral femoral epicondyle on the outside of the knee. Women are more prone for hip IT Band pain, and men more prone for knee IT Band pain. The stretches should be done 2 sets of 30 second count/5 deep breathes, and 5 to 10 times per day. Many runners can feel it coming on (called prodrome symptoms) and can stretch it out before the pain gets too intense. I had one patient who would feel it around 2 miles into a run, and was able to finish the Tahiti Marathon by stopping every 2 miles to stretch out the band. Most of the time however, subsequent stretches gives less time running (diminishing returns). The ethafoam roller can be used each morning and evening to elongate the fibers. Never use the roller over the boney prominences at the hip or knee. If stretching ever increases the pain, stop immediately and consult with your health care provider. You may have bursitis, nerve pain, hip joint pain, or a stress fracture. For normal ilio tibial band tendinitis, the stretching is a very relaxing exercise and the symptoms feel better (at least temporarily).