Chiropractic Management of Bilateral Hip Pain in an Adult Male with Moderate Osteoarthritis in an Interdisciplinary Setting
Jamie Zeman, DC1, Gina Bonavito-Larragoite, DC, FIAMA2
1Chiropractic Resident, Canandaigua VAMC
2 Chiropractor, Iowa City VAMC
Published: September 2018
Journal of the Academy of Chiropractic Orthopedists
September 2018, Volume 15, Issue 3
This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The article copyright belongs to the author and the Academy of Chiropractic Orthopedists and is available at: http://www.dcorthoacademy.com. © 2018 Zeman/Bonavito-Larragoite and the Academy of Chiropractic Orthopedists.
There is limited evidence on interdisciplinary chiropractic care for conservative management of hip pain and osteoarthritis. The intention of this report is to describe the treatment and outcomes of a 75-year-old male with a primary complaint of chronic bilateral hip pain. History and examination led to a diagnosis of moderate bilateral hip osteoarthritis with associated segmental and somatic dysfunction and muscle spasm. As suggested by the patient’s primary care provider the patient began trials of care with chiropractic and physical therapy concurrently, with treatment including spinal and extremity manipulative therapy, home exercises, and patient education. Following 6 weeks of care the patient appreciated a decrease in pain and reported improved function in activities of daily living. The patient responded well to a combination of chiropractic care, physical therapy, education and lifestyle recommendations. In this case, an interdisciplinary approach to care was beneficial for the patient. One randomized control trial  was found which suggests manual therapies combined with patient education are effective in treating hip osteoarthritis, however more research needs to be done to determine long term efficacy.
Keywords: hip osteoarthritis, hip pain, interdisciplinary, chiropractic
The purpose of this report is to present a case managing hip pain and osteoarthritis in an adult male patient seeking care within the Veterans Affairs Healthcare System with an interdisciplinary approach consisting of chiropractic care, physical therapy, and primary care.
Osteoarthritis (OA) of the femoral-acetabular joint is a joint disorder characterized by articular cartilage loss, osteophyte formation, and sclerosis at joint margins. Typical patient presentation is gradual onset of pain that is relieved with rest. Decreased internal rotation or pain increased on rotation when the knee is in full extension is a strong clinical indicator of osteoarthritis. 
The prevalence of hip osteoarthritis is approximately 5% in the population greater than or at 65 years of age, affecting women more than men. Common symptoms include joint pain and stiffness, however not all patients with hip OA are symptomatic. Risk factors included older age, history of hip injury, and excess body weight. It is more common in those with a history of femoral acetabular impingement, hip dysplasia, and rheumatoid arthritis. There is a higher incidence in those with a history of high-impact sports, especially running, and occupations with heavy lifting. 
Management of hip osteoarthritis focuses on decreasing pain and improving function. Evidence guidelines strongly recommend [2-4] patient education as part of treatment. Common non-pharmacologic interventions include orthotics, walking aids, aerobic exercise, muscle strengthening, and range of motion exercises. Pharmacologic intervention may include an NSAID regimen, weak opioids or narcotics, inter-articular corticosteroid injections, and joint replacement surgery or osteotomy if unresponsive to conservative treatment methods. 
There is limited research on management of hip osteoarthritis with chiropractic and integrative care. Typical treatment recommendations do not include chiropractic and acupuncture. There are currently no recommendations regarding treatment protocol for management of hip pain with chiropractic care.
The patient was a 75-year-old male veteran, 61 inches tall and 175 pounds with a BMI of 33.1. His past medical history was significant for type II diabetes, history of atrial fibrillation, hypertension, and hyperlipidemia, all well controlled, as well as a right total knee arthroplasty in 2005.
History revealed symptoms of chronic episodic bilateral hip pain, beginning several years prior, with periods of exacerbation typically lasting months out of the year. The most recent exacerbation occurred in Fall 2017, 2 months before his initial chiropractic consultation. He stated the pain is worse in the morning, during transitional movement such as sit-to-stand, when sleeping, during cold weather, and when initiating movement after a period of inactivity. The pain is relieved by taking Tylenol daily and applying the topical analgesic, BioFreeze. He described the quality of the pain as a nagging soreness with pins and needles. He described and pointed to the pain in the region of the buttocks and wrapping around the femoral-acetabular joint into the groin area bilaterally in what is known as a C sign pain distribution.  Patient denied radiation of symptoms into lower extremities and also denied changes in bowel or bladder function. He rateed his pain as an average of 5/10 on a daily basis, with occasional pain levels of 7/10 at worst on a numerical pain rating scale where 0 is no pain and 10 is worst possible pain. Since onset the symptoms had became more constant and had increased slightly in intensity. Patient reported he experienced daily hamstring and calf cramps, which lasted a few minutes. He stated he had difficulty walking and donning socks. He reported drinking 2 cups of water per day, and sleeping 6.5 hours per night on either side.
Physical examination revealed blood pressure in the pre-hypertensive range, and all other vitals were within normal limits. Observation revealed antalgic gait with shortened stride and severely limited extension during terminal stance phase bilaterally. Posture analysis revealed an elevated left shoulder, left external foot flare, and moderate left genu varum. Palpatory findings included hypertonicity and tenderness along the iliopsoas, hamstring, calf, iliotibial band, and trochanters bilaterally. Active range of motion was mildly limited in lumbar extension with reported stiffness. Neurologic examination revealed deep tendon reflexes, myotomes, and sensory dermatomes were all within normal limits. Orthopedic test FABER demonstrated decreased abduction with adductor tension bilaterally, and ipsilateral Yeoman’s produced pain in the left groin and in the region of the left sacroiliac joint.
A five view radiograph series of bilateral hips including the pelvis obtained at the beginning of trial of care revealed prominent degenerative change to the lumbar spine and moderate bilateral arthritis of the hip with significant joint narrowing and osteophytosis, nearly symmetric. MRI of the lumbar spine revealed degenerative disc disease with multilevel central canal stenosis and neuroforaminal narrowing, worst at lower levels, and mild retrolisthesis of L3 on L4 and L4 on L5. There was no evidence of fracture, infection, or necrosis.
The clinical impression was bilateral hip pain with associated segmental and somatic dysfunction and muscle spasm, complicated by moderate osteoarthritis of the hips bilaterally, and history of right total knee arthroplasty with severe left knee genu varum.
Intervention and Outcome
Treatment protocol included chiropractic adjusting techniques: activator protocol once per week for 4 weeks initially with chiropractic evaluation and instrument assisted spinal manipulation when clinically indicated to the sacrum, pelvis, thoracic and lumbar spine, left tibia, and femoro-acetabular joints. The chiropractic treatment plan included supportive procedures of myofascial trigger point to iliopsoas, quadratus lumborum, and iliotibial band. The patient was given home care instructions to increase water intake to 8 cups per day, and prone lumbar extension to be performed twice each morning and evening, hold for 20 seconds. The chiropractic clinic also prescribed a contoured leg pillow to assist in comfort with side sleeping. Rehabilitative procedures were co-managed with physical therapist. The physical therapist prescribed the following home exercise plan: daily exercises of hamstring stretch 2×20 seconds, lunge hip flexor stretch 2×20 seconds, and figure 4 or seated piriformis stretch 2×20 seconds, along with every other day exercises of standing hip extension 3×10, and standing hip abduction 3×10 repetitions.
The patient reported no pain at the 4th and 5th follow up, 6 weeks after initiating chiropractic care and physical therapy. His nighttime muscle spasms ceased. The patient was discharged after 5 visits. The patient’s gait improved, with slightly larger steps. As treatment progressed fewer segmental restrictions were noted, suggesting a positive response to treatment. The patient had improved ability to manage symptoms on his own. Of other interest, patient reported diabetes finger prick tests were easier at time of discharge. Patient showed interest in yoga classes, and consult was placed, patient had not attended any yoga sessions at time this paper was written.
The PROMIS outcome measure used did not reflect improvement. Initial patient intake described pain when traversing stairs, walking for more than 15 minutes, shopping, and completing house chores. At time of discharge patient reported no pain during any activities of daily living. The Numerical Pain Rating Scale (NRS) and patient reported improvement in activities of daily living were the primary indicators of patient progress and indication for discharge.
The patient responded well to a combination of chiropractic care, physical therapy, education, and lifestyle recommendations. It is hypothesized that manipulative therapy to the segments of the lumbar spine, pelvis, sacrum, and femoro-acetebular joint helped to increase motion and reduce stress on the femoro-acetabular joint, surrounding ligaments, and hip girdle musculature. The patient was compliant with home care recommendations. The contoured leg pillow served to mitigate femoro-acetabular impingement by reducing adduction and internal rotation during side sleeping. The patient reported subjective improvement in gait and lower extremity strength.
An article  reviewed the pain referral distribution pattern demonstrated by 109 patients with clinical and radiographically diagnosed hip osteoarthritis. The patients were given a numerical pain scale to rate their current pain and a mannequin to mark the location of their pain. Researchers found the most common regions marked where the greater trochanter (77%), the groin (53%), the anterior lateral thigh (42%), and the buttock region (38%). A small percent marked the knee and lower leg area. In this case study the patient presented with pain points over the greater trochanter bilaterally and myofascial trigger points in the gluteal region. The patient was instructed in a home exercise program including stretches for the iliotibial band and external hip rotators. It is possible the pain points the patient demonstrated were referrals from the femoro-acetabular region and not due to myofascial trigger points. However, in this case the potential benefit of addressing the muscular component as a potential contributor of symptoms was a reasonable management plan.
In a randomized controlled trial  researchers studied the effects of a patient education program with and without the use of manual therapy including trigger point muscular release and joint manipulation by a chiropractor compared to a minimal control intervention group for the treatment of osteoarthritis in 119 patients. Patients were treated for six weeks with a one year follow up. The outcome measure was a checkbox numerical pain rating scale. Patient education was delivered by a physical therapist for five sessions. The chiropractic group included five education sessions with twelve chiropractic appointments. The comparison group was given stretches to complete at home. The authors concluded that manual therapy combined with patient education was more effective than patient education alone.
In this case study, each chiropractic patient visit included home care recommendations and education. The results of the RCT  helps to emphasize the effect of chiropractic treatment with the current case study. Manipulative therapy provided as part of this treatment plan may have contributed to the patient’s positive response, and it is possible that the patient may not have responded as well to a treatment plan of home exercises and education alone.
An updated literature review  included 4 new clinical trials that studied treatment methods for osteoarthritis of the hip in addition to the UK Evidence report  regarding manual therapies. The updated studies included in the search criteria were chiropractic care with or without multimodal therapy, which may include physical rehabilitation, home exercises, education, and medicine. The authors concluded there was a fair level of evidence that manual therapy in combination with multi-modal therapies are effective for short term treatment of osteoarthritis of the hip. There is limited evidence to suggest that manual therapy in combination with multi-modal therapies are effective in long term treatment. The authors state there are few published studies that follow the patients long enough to determine the lasing benefit of manipulation for osteoarthritis of the hip.
A 2016 study by Beselga et al.  treated 40 adult patients with symptomatic osteoarthritis of the hip with intervention of mobilization with movement or a sham mobilization with movement. The outcomes studied were pain, orthopedic exam, and functional tests. For the intervention group, pain on the NRS decreased by 2 points, with clinically relevant increases in range of motion and improvements in functional tests. The short-term outcomes of this study were promising even though the sample size was small. Long term efficacy of this treatment was not measured in this study.
No manual mobilization with active or passive joint movement was utilized in this case study. Neither the chiropractor or physical therapist performed functional tests on this patient. Specific functional tests could have been used as additional outcome tools as well as specific questionnaires targeting daily function.
This case study supports co-managing patients with bilateral hip pain related to osteoarthritis. Hip mobility is important for quality of life, patient mobility, and independence. Current research and clinical practice guidelines support education, home care recommendations, and physical therapy. There is limited research regarding the management of hip pain with chiropractic care specifically; however, some evidence does suggest manipulative therapy is palliative for femoro-acetabular pain.  Physical therapy and home care recommendations are common non-invasive and non-pharmacological forms of treatment, but chiropractic may be a promising addition or alternative to pain management and functional improvement.
This case study was limited in duration of follow up. This patient was followed for 6 weeks before being discharged after being asymptomatic for 3 weeks. The initial examination and functional exam could have been more comprehensive for the purpose of tracking patient outcomes. As the patient in this case was treated with a multi-disciplinary care approach, it is not clear which intervention may have been the most beneficial or whether a synergistic effect may exist.
Future work on bilateral hip pain related to osteoarthritis could include proposed methods for a case-control study and randomized control study comparing chiropractic care alone, physical therapy alone, and a combination of physical therapy and chiropractic care for the management of hip pain and improving function. It would also be beneficial to develop a template for developing a case series of similar patients to create consistency in outcome measures including a standard questionnaire, functional and orthopedic exam, and radiographic criteria.
This case report may generate interest in the management of bilateral hip pain with conservative interdisciplinary care as a primary treatment protocol. In this case a combination of physical therapy and chiropractic care initiated by referrals from the primary care provider was an effective form of treatment for bilateral hip pain related to moderate osteoarthritis in decreasing pain and improving function.
1. Poulsen E, Hartvigsen J, Christensen HW, Roos EM, Vach W, et al.: Patient education with or without manual therapy compared to a control group in patients with osteoarthritis of the hip A proof-of-principle three-arm parallel group randomized clinical trial. Osteoarthritis Cartilage 2013, Oct 21(10):1494-503. PubMed PMID: 23792189.
2. Aresti N, Kassam J, Nicholas N, Achan P: Hip osteoarthritis. BMJ. 2016 Jul 6:354:i3405.
3. Byrd T: Evaluation of the Hip: History and Physical Examination. N Am J Sports Phys Ther. 2007 Nov 2(4):231-240.
4. Poulsen E, Overgaard S, Vestergaard JT, Christensen HW, Hartvigsen J: Pain distribution in primary care patients with hip osteoarthritis. Fam Pract. 2016 Dec 33(6):601-606.
5. Brantingham JW, Bonnefin D, Perle SM, Cassa TK, Globe G, et al: Manipulative therapy for lower extremity conditions: update of a literature review. J Manipulative Physiol Ther. 2012 Feb 35(2):127-66.
6. Bronfort G, Haas M, Evans R, Leininger B, Triano J: Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010 Feb 25:18:3.
7. Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N: Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: A randomised controlled trial. Man Ther. 2016 Apr 22:80-5.