Treatment of hip microinstability and gluteal tendinopathies involves movement control and exercise

Abstract

A musculoskeletal therapist or exercise professional will often see patients or clients of different ages, sexes and fitness levels who present with issues that can be related to imbalances in muscles that control movement at and across the hip. These issues involve complex patterns of cause and effect and can be observed whether an individual is inactive or participates in high level sports or performance disciplines. Habitual postural sway in which the trunk moves back relative to the pelvis disadvantages the gluteal muscles and biases active postural control to the 2-joint hamstrings, making them inextensible and short (Sahrmann, 2002Sahrmann S. Diagnosis and Treatment of Movement Impairment Syndromes. Mosby, 2002Google Scholar). Undergraduate ballet dancers can cheat their turn out at the knee rather than create the required external rotation at the hip. They may also anteriorly tilt their pelvis so that the tensor fascia lata (TFL) musculature restricts the hips ability to turn out, and at the other end of the ilio-tibial band (ITB) can increase external rotation of the tibia due to the shortened TFL/ITB. A mature woman can report lateral hip pain at night in bed when they sleep on their side with the pain coming from either hip, caused by compressive forces. The lower most hip's gluteal tendons, bursae and fascia are directly compressed and the adducted position of the upper-most leg places a longitudinal tensile force on its ipsilateral structures. A football player diagnosed with a cam type femoral acetabular impingement (FAI), a morphological change at the head and neck of the femur consisting of an overgrowth or exotosis of bone that impinges the femur on the labrum and acetabular rim (Kuhlman and Domb, 2009Kuhlman G. Domb B. Hip impingement: identifying and treating a common cause of hip pain.Am. Fam. Physician. 2009; 80: 1429-1434PubMed Google Scholar) during vigorous hip movement (Sankar et al., 2013Sankar Wudbhav N. et al.Femoroacetabular impingement: defining the condition and its role in the pathophysiology of osteoarthritis.J. Am. Acad. Orthop. Surg. 2013; 21: S7-S15Crossref PubMed Scopus (124) Google Scholar), may find their post surgical muscular balance is subtly affected, and a reported lack of return to normal gait patterns may contribute in the long term to degenerative changes the surgery was intended to prevent (Brisson et al., 2013Brisson N. Lamontagne M. Kennedy M. Beaulé P. The effects of cam femoroacetabular impingement corrective surgery on lower-extremity gait biomechanics.Gait Posture. 2013; 37: 258-263Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar). In recent years the understanding of the hip has broadened from looking at the often surgical treatment of the osteoarthritic (OA), degenerative hip in the older population to conditions often affecting the younger, and sometimes more active, individual; Labral tears and FAI – conditions that can be inter-related and are implicated in later degeneration of the hip (Bedi et al., 2011Bedi A. Dolan M. Leunig M. Kelly B. Static and dynamic mechanical causes of hip pain.Arthrosc. J. Arthrosc. Relat. Surg. 2011; 27: 235-251Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar). Gluteal tendinopathies are also becoming better understood and are identified as a primary local source of lateral hip pain, though high quality research on both diagnostic tests and management are still lacking (Grimaldi and Fearon, 2015Grimaldi A. Fearon A. Gluteal tendinopathy: integrating pathomechanics and clinical features in its management.J. Orthop. Sports Phys. Ther. 2015; 45: 910-922Crossref Scopus (54) Google Scholar). A recent review paper by Kalisvart and Safran, 2015Kalisvart M. Safran M. Microinstability of the hip—it does exist: etiology, diagnosis and treatment.J. Hip Preserv. Surg. 2015; 2: 123-135Crossref Google Scholar differentiates between the well understood traumatic dislocation and subluxation of the hip and symptomatic hip ‘microinstability’ commenting that ‘it is more poorly defined, has a less dramatic clinical presentation, lacks consistent objective evaluative criteria, and has only recently emerged as a significant cause of pain and disability in younger patients and athletes’. They report findings that suggest ligamentous laxity and peri-articular muscular weakness are potential causes, as well as subtle anatomic abnormalities associated with activities such as golf, figure skating, gymnastics, ballet, martial arts, baseball, tennis and football, which involve repetitive rotational hip movements, or axial loading of the hip, which can increase the translatory movement (2–5 mm) of the femoral head relative to the acetabulum. It is this undesirable joint play that may contribute to damage of the labrum, joint cartilage and capsular structures. Anatomically the hip is considered to be stable as it has passive, active and neural factors that act synergistically to create stability (Retchford et al., 2013Retchford T. Crossley K. Grimaldi A. Kemp J. Cowan S. Can local muscles augment stability in the hip? A narrative literature review.J Musculoskelet. Neuronal Interact. 2013; 13: 1-12PubMed Google Scholar). The passive elements involve the skeletal architecture of the acetabular socket, the relatively small femoral head (when compared to the gleno-humeral joint), the capsuloligamentous structures and the labrum. The 3–8 mm width of the labrum increases the acetabular volume by about 20% (Tan et al., 2001Tan V. Seldes R. Katz M. Freedhand A. Klimkiewicz J. Fitzgerald R. Contribution of acetabular labrum to articulating surface area and femoral head coverage in adult hip joints: an anatomic study in cadavera.Am. J. Orthop. 2001; 30: 809-812PubMed Google Scholar), not only increasing coverage of the femoral head by the combined soft tissue and bony acetabular structure but also creating a seal that uses suction to help provide further stability. A labral tear reduces the force required to distract the hip joint by 60% (Crawford et al., 2007Crawford M. Dy C. Alexander J. Thompson M. Schroder S. Vega C. Patel R. Miller A. McCarthy J. Lowe W. Noble P. The 2007 Frank Stinchfield award. The biomechanics of the hip labrum and the stability of the hip.Clin. Orthop. Relat. Res. 2007; 464: 16-22Google Scholar) highlighting the labrum's importance in hip joint stability. The capsuloligamentous structure of the hip consists of 3 ligaments – the iliofemoral ligament (ILFL), pubofemoral ligament (PFL) and ischiofemoral ligament (ISFL) – that spiral around the femoral head and combine with the circular zona orbiculares so that in extension abduction and internal rotation of the hip joint the tightening ligaments provide compression of the femoral head into the acetabulum. This is called the closed pack position. Hip flexion, combined with adduction and external rotation (the open pack position), is the position that the capsuloligamentous structure is at its most unconstrained as the bony stability provided by the set of the position of the acetabulum is at its greatest. Retchford et al., 2013Retchford T. Crossley K. Grimaldi A. Kemp J. Cowan S. Can local muscles augment stability in the hip? A narrative literature review.J Musculoskelet. Neuronal Interact. 2013; 13: 1-12PubMed Google Scholar highlights that only the periphery of the acetabulum articulates with femoral head and in stance the anterior and superior part of the femoral head is exposed allowing greater flexion but increasing reliance on the anterior soft tissues and connective tissue structures for stability during hip extension. The acetabulum is anteverted (inclined forward), anteriorly tilted (gently facing inferiorly) by 10–15° and laterally tilted by 45° in the pelvis. The neck of the femur has 130 degrees of superior inclination from the shaft (neck-shaft angle) and is in 10 degrees of anteversion (Kalisvart and Safran, 2015Kalisvart M. Safran M. Microinstability of the hip—it does exist: etiology, diagnosis and treatment.J. Hip Preserv. Surg. 2015; 2: 123-135Crossref Google Scholar) but bony variance occurs. In conditions such as dysplasia in which the acetabulum is shallow, and its opposite variation, where the acetabulum appears ‘too deep’, gives rise to pincer type FAI. ‘Under coverage’ of the femoral head occurs in dysplasia, placing more stress on the labrum, and ‘over coverage’ occurs in pincer type FAI, allowing abutment of the femur on to the acetabular rim and labrum, leading to damage at the impact points and an increase in shear forces with potentially negative consequences at tissue interfaces. It is not a surprise then that dysplasia and FAI are considered the two most common causes of OA (Bedi et al., 2011Bedi A. Dolan M. Leunig M. Kelly B. Static and dynamic mechanical causes of hip pain.Arthrosc. J. Arthrosc. Relat. Surg. 2011; 27: 235-251Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar), although longitudinal research indicates a predisposition to OA in certain patients with FAI, it is not clear yet what type and severity of intra-articular damage is required before there is a longer term risk of developing clinically significant hip OA (Sankar et al., 2013Sankar Wudbhav N. et al.Femoroacetabular impingement: defining the condition and its role in the pathophysiology of osteoarthritis.J. Am. Acad. Orthop. Surg. 2013; 21: S7-S15Crossref PubMed Scopus (124) Google Scholar). The active systems that create hip stability consist of the muscles around the hip. Retchford et al., 2013Retchford T. Crossley K. Grimaldi A. Kemp J. Cowan S. Can local muscles augment stability in the hip? A narrative literature review.J Musculoskelet. Neuronal Interact. 2013; 13: 1-12PubMed Google Scholar (see Table 1) summarises succinctly the current theorised interaction between local muscles' capacity to provide joint stabilisation and global muscle activity about the hip by referring to lumbar, cervical, and shoulder research. ‘Muscles that can generate large forces over small changes in muscle length and muscles that have lines of forces predominately creating joint compression could be considered to be primary active stabilisers’. Local muscles being physically deep and fatigue resistant are suited to postural control when acting synergistically. They use feed forward systems to improve postural control, whereas global muscles with their larger cross sectional area (CSA), and greater moment arms are more effective in generating force and accelerating joint motion. In pathological situations the local muscles may become inhibited and the global muscles may become over-active. Recruitment pattern changes in muscles around the Sacro-iliac joint (SIJ) have been shown that supports this argument (Hungerford et al., 2003Hungerford B. Gilleard W. Hodges P. Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain.Spine. 2003; 28: 1593-1600PubMed Google Scholar). Retchford et al. propose that specificity of exercise improves inhibited local muscle activation, and warn that prescribing non-specific training, in which both local and global muscles contract, before local muscle function returns, may delay recovery (2013). Many therapists, influenced by Janda's approach, may treat the hypertonicity first before attending to the under-recruited muscles (Janda, 1983Janda V. Muscle Function Testing. Butterworths, London1983Google Scholar) (Table 1).Table 1Deeper (stabilising) and abducting hip musculature – key points from Retchford et al., 2013Retchford T. Crossley K. Grimaldi A. Kemp J. Cowan S. Can local muscles augment stability in the hip? A narrative literature review.J Musculoskelet. Neuronal Interact. 2013; 13: 1-12PubMed Google Scholar.Deep external rotators-The quadratus femoris, obturator internus and externus and the gemelli-Proposed to be key active stabilisers of the hip- With gluteus minimis make up the ‘rotator cuff of the hip’- Low force generators of rotation- May provide ‘subtle’ hip position adjustment- Quadratus femoris may have more local muscle attributes compared to the other muscles in this group- Animal studies suggest a proprioceptive role in this muscle group (due to high percentage of slow twitch fibres and therefore muscle spindles in the quadratus femoris)Iliocapsularis- A muscle not well described in anatomical texts- Reinforces the anterior capsule of the hip potentially tightening the capsule and improving stabilityPiriformis-Piriformis is most active in resisted external rotation of the hip-Piriformis has a high ratio of CSA to fibre length suggesting a potential stability role, though the line of force does not enhance joint compressionGluteus minimis-Although the gluteus minimis is an abductor, rotator and flexor of the hip it's primary function is to stabilise the hip and pelvis-As the fibres run parallel with the neck of the femur it is an important stabiliser of the femoral head in the acetabulum-The anterior portion is active in prone hip extension and late stance phase providing anterior support to the jointGluteus medius-The primary abductor of the hip-Important stabiliser of pelvis and hip-Limits pelvic drop and hip adduction in single leg stance-3 separate segments with different fibre orientation and innervation anterior, middle and posterior-Anterior portion creates pelvic rotation, and active in hip extension perhaps controlling anterior femoral head translation-Middle portion initiates hip abduction-Posterior portion in gait stabilises the femoral head within the acetabulum-Due to its large abduction moment arm gluteus medius is better suited to produce force, stabilising the pelvis in weight bearing, as opposed to the optimal positioning of the femoral head in the acetabulum in functionIliopsoas-Active in hip flexion-Psoas has more fast twitch fibres-Iliiacus has more slow twitch fibres (animal studies) therefore likely a stabiliser of the hip especially in late stance phase in gait Open table in a new tab Perhaps a reason that recognition of FAI, labral tears and other non arthritic groin related pain, is a relatively recent area of research into hip pathologies is the difficulty in differentially diagnosing hip and groin related symptoms. For example a Sports hernia or ‘athletic pubalgia’ is painful and often ascribed to overuse. It can present with weakness or a tear of the posterior inguinal wall but without a clinically recognisable hernia. It can also present with insertional injury of the rectus abdominis (Kahn et al., 2013Kahn W. Zoga A.C. Meyers W.C. Magnetic resonance imaging of athletic pubalgia and the sports hernia, current understanding and practice.Magn. Reson Imaging Clin. N. Am. 2013; 21: 97-110Abstract Full Text Full Text PDF Scopus (36) Google Scholar), oblique muscle avulsion at the pubic tubercle, or injury within the internal oblique or the external oblique aponeurosis (Gilmores's groin). Bedi et al., 2011Bedi A. Dolan M. Leunig M. Kelly B. Static and dynamic mechanical causes of hip pain.Arthrosc. J. Arthrosc. Relat. Surg. 2011; 27: 235-251Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar report that this often is present in athletes with FAI, limiting hip flexion and internal rotation thereby creating abnormal movement of the hemi-pelvis. ‘When the functional range of motion (ROM) required to compete in sports is greater than the physiologic motion allowed by the hip, compensation may occur in the lumbar spine, sacroiliac joint, pubic symphysis and posterior hip subluxation’. This in turn can affect the muscles across the pelvis and create issues in adductor longus, the proximal hamstrings, the abductors, iliopsoas and the hip flexors. High energy twisting in sports, trunk hyperextension and hyper-abduction are actions implicated in athletes with stronger adductors and relatively weaker lower abdominals. The pain is in the anterio-medial hip but can refer to the adductors, perineum, testicle or rectus abdominis, it increases on activity and reduces with rest. Surgical repair with or without mesh can be offered if conservative approaches are not successful. A case study, presented in this Prevention and Rehabilitation section, by Navot and Kalichman, 2016Navot S. Kalichman L. Hip and groin pain in a cyclist resolved after performing a pelvic floor fascial mobilization.J. Bodyw. Mov. Ther. 2016; 20: 604-609Abstract Full Text Full Text PDF Scopus (4) Google Scholar, shows also that the pelvic floor musculature can be a source of hip and groin pain. As 90% of all patients with labral pathology have associated bony deformities (Bedi et al., 2011Bedi A. Dolan M. Leunig M. Kelly B. Static and dynamic mechanical causes of hip pain.Arthrosc. J. Arthrosc. Relat. Surg. 2011; 27: 235-251Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar) labral tears and FAI's have similar presentations, it is not until imaging is undertaken that altered bony morphology can be visualised. Labral tears present with anterior hip or groin pain and sometimes buttock pain. Patients often indicate the site of the pain with the ‘C’-sign - making a C with the thumb and index finger and cupping the anterior hip region with the fingers at the fold of the hip. Frequently there are mechanical signs, most commonly, clicking, but symptoms can also include locking and giving way. Pain is often insidious with up to 74% not associated with any known specific event or cause, and is thought to be due to repetitive microtrauma (Lewis and Sahrmann, 2006Lewis C.L. Sahrmann S.A. Acetabular labral tears.Phys. Ther. 2006; 86: 110-121Crossref PubMed Scopus (111) Google Scholar). A diagnosis can take over 2 years to be made (Groh and Herrera, 2009Groh M. Herrera J. A comprehensive review of hip labral tears.Curr. Rev. Musculoskelet. Med. 2009; 2: 105-117Crossref PubMed Scopus (164) Google Scholar). The pain can worsen with prolonged sitting, standing or walking or can be associated with specific hip positions or sports movements, particularly actions involving rotation about the hip. Posturally the patient may stand in anterior or posterior pelvic tilt (Cheatham et al., 2016Cheatham S. Enseki K. Kolber M. The clinical presentation of individuals with femoral acetabular impingement and labral tears: a narrative review of the evidence.J. Bodyw. Mov. Ther. 2016; 20: 346-355Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar). The most consistent tests for labral tears are positive anterior hip impingement tests such as the FADIR (Flexion adduction internal rotation), tested in a supine position with the hip and knee flexed to 90°, with the hip adducted and internally rotated with over-pressure, or the flexion internal rotation test, which is similar to the FADIR but without the adduction element. Muscular weakness can be detected in the muscles that flex, extend, abduct, adduct or externally rotate the hip, and tightness can be found in the iliopsoas muscle (Cheatham et al., 2016Cheatham S. Enseki K. Kolber M. The clinical presentation of individuals with femoral acetabular impingement and labral tears: a narrative review of the evidence.J. Bodyw. Mov. Ther. 2016; 20: 346-355Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar). All imaging needs to be related to the clinical history and test findings. Radiographs are important particularly in FAI. The identification of pincer lesions, related to over-coverage of the femoral head allowing the acetabular rim to impinge on the proximal femur, or cam lesions, which are related to bony changes (exotosis or bony overgrowth) at the neck or head of the femur, or indeed the common combined ‘pincer and cam’ lesions, which can be seen radiographically. Magnetic Resonance Imaging (MRI) and Magnetic Resonance Arthrography (MRA) are the preferred techniques for diagnosing intra-articular hip pathologies. Magnetic resonance imaging without arthrography has limited sensitivity (25–30 percent) for labral tears but arthrography improves the sensitivity to 90 to 92 percent (Kuhlman and Domb, 2009Kuhlman G. Domb B. Hip impingement: identifying and treating a common cause of hip pain.Am. Fam. Physician. 2009; 80: 1429-1434PubMed Google Scholar). As many as 60% of patients requiring hip arthroscopy are initially misdiagnosed (Domb et al., 2009Domb B. Brooks A. Byrd J. Clinical examination of the hip joint in athletes.J. Sport Rehabil. 2009; 18: 3-23Crossref PubMed Scopus (51) Google Scholar). Arthroscopy is regarded as the gold standard for the diagnosis of a labral tear. As of 2009 Kuhlman and Dome reported that there were no published studies of non-surgical treatment of FAI. A home programme of self-administered manual therapy was proposed by Wright and Hegedus, 2012Wright A. Hegedus E. Augmented home exercise program for a 37-year-old female with a clinical presentation of femoroacetabular impingement.Man. Ther. 2012; 17: 358-363Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, their case study suggesting a good result. Botha et al., 2014Botha N. Warner M. Gimpel M. Mottram S. Comerford M. Stokes M. Movement patterns during a small knee bend test in academy footballers with femoroacetabular impingement (FAI).Work. Pap. Health Sci. 2014; 1 (ISSN 2051-6266/20140056)Google Scholar, looking at movement patterns in young academy level footballers with diagnosed symptomatic FAI on MRI, found that the cohort of 9 all showed movement control faults on testing a single leg, small knee bend movement. They all had altered movement patterns related to hip flexion. Reduced capacity to control medial rotation of the femur was also present, indicating under engagement of the gluteus medius. As young footballers are known to develop cam type deformities from the age of 13 when compared to their non-athletic peers (Agricola et al., 2011Agricola R. Heijboer M. Ginai A. Van Der Heijden R. Verhaar J. Weinans H. Waarsing J. The occurrence of cam impingement in young male soccer players.Osteoarthr. Cartil. 2011; 19: S168-S169Abstract Full Text PDF Google Scholar) it is plausible that an increased volume and intensity of training at a young age, with high repetition of bone loading cycles across their joints, may increase their risk of later injury and the development of OA. If accepted, the hypothesis of a link between motor control training and loading effects during dynamic actions, supports the importance of teaching strategies to control hip flexion and medial hip rotation using particularly the gluteus maximus and gluteus medius. Evidence in support of this is provided by a study in an elite rower, with a persistence of pain post FAI corrective arthroscopic surgery who responded well to a 16 week movement control assessment and retraining process (Mottram et al., 2015Mottram S. Warner M. Steenman K. Botha N. Stokes M. Movement control retraining in an elite rower with persistent pain post arthroscopy for Femoroacetabular impingement: proof of concept case report.WCPT Congr./Physiother. 2015; 101: eS833-eS1237http://dx.doi.org/10.1016/j.physio.2015.03.1930Google Scholar) suggesting that conservative treatment approaches focussed on movement control can be successful after an operative intervention. In 2006 Lewis and Sahrmann reported that they had found no previous published articles on physical therapy intervention for labral tears. They advocated physical therapy aimed at reducing anteriorly directed forces on the hip by addressing the patterns of recruitment of muscles that control hip motion, hip extension and during gait. They teach the avoidance of loaded pivoting motions of the acetabulum on the femur. Lewis and Sahrmann report finding subtle increases in accessory hip joint motion during flexion and external rotation (possibly what Kalisvaart and Safran today would refer to as microinstabilities). Overall Physical Therapy should aim, suggests Lewis and Sahrmann, ‘to optimise the alignment of the hip joint and the precision of joint motion.’ (Table 2).Table 2Lewis and Sahrmann: suggested key elements for the physical therapy for labral tears.Examination prior to treatment should look for-Hip hyperextension: evident with knee hyperextension or pelvic posterior tilt-Hyperextension of the hip in gait-Precision of active and passive hip flexion-Prone hip extension patterns (looking for the appropriate contribution of gluteus maximus)-The pattern and range of hip rotation in prone and sitting-Hip joint alignment in the quadruped position, and during rocking back movements-Muscle strength and patterns of control of the: hip abductors, gluteus maximus, iliopsoas, and deep lateral rotator muscles-Sitting habits: looking for crossed knees, sitting on legs, perch sitting (biasing superficial hip flexors), not sitting on ischial tuberosities-Rotation of the pelvis getting up from a chair or out of a car Open table in a new tab Khoo-Summers and Bloom, 2015Khoo-Summers L. Bloom N. Examination and treatment of a professional ballet dancer with a suspected acetabular labral tear: a case report.Man. Ther. 2015; 20: 623-629Abstract Full Text Full Text PDF Scopus (9) Google Scholar present a case study in which Lewis and Sahrmann's suggested assessment and treatment principles are applied to a classical ballet dancer, a group very vulnerable to labral tears due to the excessive ranges of hip movement required for their training, rehearsal and performances. This case study describes the assessment and decision making underlying choices of treatment exercises. It should be noted that the authors present 2 different diagnoses, one, a patho-anatomic diagnosis - the suspected labral tear – and a second ‘movement impairment’ diagnosis – in this case a ‘femoral anterior glide’, in which the ability of the professional dancer to maintain the femoral head in the socket, especially during hip extension was uncontrolled and considered to have contributed to her labral tear. A further recent case study of a young ice skater with a labral tear and no bony abnormality following similar treatment principles is described by Liem et al., 2014Liem B. Loveless M. Apple E. Krabak B. Nonoperative management of acetabular labral tear in a skeletally immature figure skater.Am. Acad. Phys. Med. Rehabil. 2014; 6: 951-955Google Scholar. The conservative approach was agreed to prior to arthroscopy due to the patient's age. The authors report that, ‘the initial focus of her treatment was on improving activation of the abdominal wall muscles, and strengthening the gluteus medius, hip external rotators, and lumbar paraspinal and multifidi while maintaining a neutral spine. Supine exercises to improve abdominal wall activation included abdominal bracing with leg lifts and heel slides, and bent-knee fall-out exercises in the hook-lying position (supine position with knees flexed and feet flat). A lumbar biofeed-back cuff was used during these supine exercises to help maintenance of a neutral spine. Additional exercises to strengthen the lumbar paraspinals and multifidi included quadruped alternate arm and leg lifts. Initial hip abductor and external rotator strengthening was achieved through clam shell and side-lying hip abduction exercises’. Her next level of exercise, ‘advanced to functional exercises including single-leg step-downs and reaches with emphasis on maintaining a level pelvis. Further training included grand plié, barre exercises, and skater-specific positions on destabilizing surfaces. She was allowed to swim to maintain cardiovascular fitness’. This conservative approach was successful without recourse to arthroscopy and she returned to low level skating, and sport specific training, slowly building up to her full competitive training, pain free, 4 months after her treatment started. These reports, albeit at the lower levels of single case study evidence, are starting to be published in the literature, and support the role of physical therapies in both the treatment of FAI's and labral tears, which have previously remained in the treatment domain of the surgeon. It should become clearer over the next few years which groups of patients may benefit from a non-surgical approach, and post-operative management may also benefit from a movement control approach that is precise and targeted to the patient. Another condition of the hip that has recently been the target of reappraisal is lateral hip pain. Traditionally lateral hip pain has been diagnosed as trochanteric bursitis, but examination findings have not confirmed that the trochanteric bursa has actually been inflamed, the diagnosis is now shifting towards recognition of this as a ‘non-inflammatory insertional tendinopathy of the gluteus medius (GMed) or gluteus minimis (GMin)’ (Grimaldi et al., 2015Grimaldi A. Mellor R. Hodges P. Bennell K. Wajswelne H. Vicenzino B. Gluteal tendinopathy: a review of mechanisms, assessment and management.Sports Med. 2015; 45: 1107-1119Crossref Scopus (86) Google Scholar). This tendinopathy affects women over 40 more than men and affects both sedentary and active people, particularly runners. Grimaldi et al. suggest that the pathomechanics of the condition are related to the loading of the tendon, either longitudinally or compressively. Graduated increases in tensile load, with adequate time for recovery and adaptation, is desirable but a failure to adapt can occur from both over or under loading (stress deprivation). The Ilio-tibial band (ITB) may compress the tendons and the associated bursae at the greater trochanter and this effect can be increased further with greater degrees of adduction at the hip in both static postures, such as standing out on one hip, and in movement. An incorrect balance of load into the tensor fascia lata (TFL), vastus lateralis (VL) and upper gluteus maximus (UGM) – the abducting part of the gluteus maximus – may