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What is Clinical Pilates?

Clinical Pilates is a Physiotherapy led functional and dynamic exercise programme focused on retraining normal patterns of movement from a central stable core. This rehabilitation method is particularly effective in correcting the biomechanical imbalances around the hip, lumbar spine and pelvis through exercises that isolate the proximal hip and core muscles. Strengthening these deep stability muscles can help to correct muscle imbalance and improve hip joint function. It is widely popular all around the world, and you can Click here to find out about other clinics, but with a quick Google search, you will be able to find one close to you.

Pilates is different to other physiotherapy rehabilitation exercises because it concentrates specifically on “centering” which refers to activating the deep abdominal muscles, back muscles and pelvic floor in unison, while keeping the lower back in a neutral spine position. This restores the natural curves of the spine and improves body awareness by training the centre to remain active throughout the duration of the Pilates movements. If travelling to Manchester is awkward, why not visit CK Physio – London instead!

The Clinical Pilates concept of strength training is that there are different components which make up a functional core:-

Supportive Core

(Transversus Abdominus, Pelvic Floor, Multifidus, Diaphragm)

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Strength Core

(Latissimus Dorsi, Serratus Anterior, Obliques, Rectus Abdominus, Quadratus Lumborum, Gluteals, Thoroco-lumbar fascia)

+

Extremities

(Arms, legs)

=

Functional Core

Centering activates the supportive core. The controlled movements activate the strength core and the movements incorporate actions of the extremities which facilitates an effective method of core strengthening.

Alongside functional core strengthening, Pilates exercises also follow the APPI (Australian Physiotherapy & Pilates Institute) principles which include:-

  • Concentration
  • Breathing
  • Centering
  • Control
  • Precision
  • Flowing movement
  • Integrated movement patterns
  • Routine

These are all aspects which make Clinical Pilates a valuable method of strengthening.

Why Clinical Pilates for hip rehabilitation?

Every exercise in the Clinical Pilates repertoire has a particular movement focus. For example, some exercises focus on controlled strength, rotary stability, abdominal strengthening, gluteal strengthening or limb dissociation. These concentrated movements are the foundation of early stage rehabilitation from hip injury or surgery, allowing Physiotherapists to prescribe patient-centred, individualised Pilates exercises. Those who have suffered from a hip injury from a fall in Texas may find the services of a hip injury lawyer San Antonio useful in helping with a personal injury case.

Basic level Clinical Pilates exercises are often included in a thorough Physiotherapy assessment. These movements allow Physiotherapists to identify biomechanical imbalances and movement dysfunction. This facilitates the prescription of specific exercises to correct movement dysfunction and reduce hip symptoms to aid recovery.

Clinical Pilates can also help to prevent hip injury. . .

Commonly Clinical Pilates is used as a rehabilitation method in Physiotherapy for hip pain, hip dysfunction or following hip surgery. However, it is also a popular and effective method of injury prevention or prehabilitation.

Regular participation in classes will maintain and continually improve strength around the proximal hip and core muscles. This means the development of muscle imbalance, movement dysfunction or overloading leading to hip pain are less likely.

This is particularly relevant for the sporting or athletic population. A recent research study proved that a 6 week course of Clinical Pilates classes can improve functional movement and reduce the risk of injury in recreational runners (Laws et al, 2017).

Additional benefits of Clinical Pilates

Alongside improvements in core stability, flexibility and strength, Clinical Pilates has other health benefits including stress management, breathing control and relaxation. These exercises can be performed in 1:1 sessions or small group classes led by an experienced and fully qualified Physiotherapist to aid recovery from hip surgery or injury.

Anna Laws

Physiotherapist

Spire Manchester



Who does this affect?
Hip impingement is a relatively common condition in which there is a structural abnormality in either the femoral head (ball of the hip) or the pelvic cup. Normally, as the hip bends up, the bony cup and flexible cartilaginous rim (Labrum) sit into the concave femoral neck.

However, some patients have either a bump on their femoral head (cam impingement) or an over-hanging cup (pincer impingement) and this causes damage to the labrum and eventually the joint surface.

Symptoms
Patients with hip impingement present with deep seated groin pain, usually worse on bending and may be present on both sides. There may be an associated deep click, which can be either due to a torn rim cartilage, or more commonly, an inflamed tendon running over the front of the hip (Psoas Tendon). If the condition has been present for some time, there may also be inflammation of the tissues surrounding the hip such as the outer hip (trochanteric bursitis), the groin muscles (adductor tendonitis) or inflammation of tendons in front of the hip (sartorius tendonitis). Eventually, as the damage continues, the patient may begin to develop more arthritic symptoms such as a dull ache in the groin and increasing stiffness. Hip-related pain is not always felt directly over the groin, it may also be felt on the outer aspect of the thigh, the buttock or traveling down the leg. Occasionally, the pain you do feel in the hip may actually be the result a problem in your back, a hernia or other diagnoses.

Causes
Hip impingement is caused by bony abnormalities on the acetabular or pelvic rim, the femoral head (ball of the hip) or a combination of the two. Using a combination of plain x-rays and CT scans with 3-D reconstructions, it is possible to very accurately identify where the abnormality is and what needs to be removed at the time of surgery. The routine use of 3D CT has made a real difference to the success of the surgery and the eventual outcome for the patient.

Pure CAM deformity
In a CAM deformity, there is an abnormal bump at the junction between the head/ball of the femur and the neck. This is evident on the image above. This area can be accessed from within the joint and shaving carried out using a small burr until the appropriate shape has been created.

Pure PINCER deformity
In a PINCER deformity, there is an overhanging cup. This can be seen on both the plain x-rays and the CT reconstructions. Depending on the severity, the bony rim can be trimmed back leaving the soft cartilaginous rim in place (peri-labral rim recession), if it is a mild deformity or in more severe cases, by removing it, shaving back the bony rim and then reattaching the labrum using special bony anchors.

Mixed CAM/PINCER deformity
In the majority of patients, there is a combination of CAM and PINCER impingement. In these cases both sides may need to be addressed if the patient is to get the best result. This can often be achieved by doing a peri-labral rim recession and a femoral head reshaping, thereby leaving the labrum in place and allowing for early mobilisation.

Investigations
All patients undergo specialized x-rays of the hip as well as more complex scans such as CT and Magnetic Resonance Arthrography (MRA). These scans are used to confirm the soft-tissue damage and to accurately map out the bony deformity. This is very important when planning the surgery.

Non-surgical Treatment
Professor Fehily has designed a specialized hip rehabilitation program. This was done in conjunction with his specialist hip physiotherapists. This was initially developed for patients following key-hole hip surgery but it is now being used for general hip rehabilitation. Other therapies such as painkillers, anti-inflammatory drugs, for example, liquid thc, as a more natural approach, and modification of activity can also be tried.

Surgical Treatment
If the hip impingement is due to an underlying bony abnormality and physiotherapy has not cured the pain then surgery is recommended. The aim is to correct the bony deformity before there is irreversible joint damage. This is usually done by hip arthroscopy (keyhole surgery) where the deformity is shaved back via 2 or 3 small incisions. Occasionally some patients with pincer impingement do not simply have an overhanging front rim, instead, the entire cup is rotated backward (acetabular retroversion). If this is the case, then a simple rim trimming will not solve the problem and by decreasing the amount of head coverage, may actually speed up the onset of arthritis. These cases may need more significant pelvic surgery to alter the position of the cup (peri-acetabular osteotomy).

Hip arthroscopy is highly specialised and technically difficult surgery but can achieve excellent results if carried out correctly and on the right patient. Based on Professor Fehilys’ own experience and that of the wider orthopaedic community, certain patients do not do well from hip arthroscopy e.g. patients with significant hip arthritis, patients with severe childhood hip disease (hip dysplasia) or patients with inflammatory hip disease (e.g. rheumatoid arthritis). Occasionally, the bony deformity may be so large that an adequate bony reshaping is not possible using key-hole surgical techniques. In those cases the operation is done using an open technique. In some cases, the damage caused to the joint by the impingement may be so severe that the only reliable option is a joint replacement. However, if at all possible, we will try to preserve the joint using a combination of techniques such as micro-fracture and stem cell treatment (see Stem Cell Therapy). All patients are different and the advantages and disadvantages of the various treatment options can be discussed at the time of your consultation.


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A painful hip can be through a one off injury but more commonly in clinic at Altius Healthcare we see pain that has come on gradually over a period of months and got worse. Patients describe a deep pain in either their groin or buttock or both and don’t recount a particular event. Their pain tends to vary in severity and is aggravated by certain movements that compress the joint surfaces including prolonged sitting. Combining physical therapy with other avenues can help people deal with the pain in a better manner. Medical marijuana has been known to aid in pain relief and depending on how you consume it, you can go and look at pipes and bongs online to find the best one for you. Alternatively, you can speak to your doctor if you are interested in using medical marijuana for pain management. Some doctors can write a prescription for you, which allows you to buy cannabis online to help give you pain relief.

Often these patients are scanned and the results of the imaging don’t match their pain presentation. Some have a large amount of damage in their hip but are relatively pain free and others are very painful with little to report on the scan.
The majority of patients (regardless of their scan results) have muscular inhibition, as a result of the pain they are in and which we can address with home exercises which almost always helps them with their pain.

Patients with painful hips tend to keep going on them until they have picked up a poor movement pattern (limp) which sets off a cascade of events that if you don’t address with treatment and rehabilitation they continue to gradually get worse.

Once you are feeling pain the important thing to do initially is to identify the things that aggravate your pain and avoid them. This may sound like common sense but you would be surprised how many people try to push through the pain only to make it worse. For instance, if prolonged sitting is a problem, record how long it takes in sitting for you to get to 4/10 severity and then use this a s a guide to make sure that you don’t exceed this pain threshold in any one day.

Do take medication as well. People will not take medication because they think it will numb them so they do not know when they are making things worse. Once you know that without medication you can only sit for 40 mins then once you are taking medication stick to this rule of not sitting for longer than 40 mins for 3 days and then reassess your progress.

A person who has had hip pain for a month or longer will normally always have inhibition in their gluteal muscles (buttocks) and adductors (groins). In clinic, we would normally always prescribe exercises to help wake these muscles up. I often suggest a single leg bridge and a ball squeeze as a good place to start. Patients with hip pain also tend to have poor trunk strength, often worse on their painful side so we would also teach a modified plank exercise in three positions to strengthen the natural corset which is so important in stabilising the spine on the pelvis and off-loading the hips.

At the same time as addressing muscular inhibition, we also encourage patients to work on their spasm. We often find in clinic if the gluteals and adductors aren’t working properly, their default is to go into spasm to stop you moving which causes you more pain. We find teaching you deep pressure techniques with a foam roller can reduce spasm and pain and be a great thing to do before you do your strengthening rehab.

Regarding how much and how often. Obviously most patients are busy people and struggle to get anything done regularly just as some patients can over do it and aggravate things further. Therefore finding a balance is important and listening to your hip and how it is feeling, is of up most importance. I always suggest doing rehab Monday, Wednesday and Friday is a good place to start. The body needs to rest and recover from the strengthening you are doing and normally I say if you are sore (less than 4/10) during the exercises and and/or afterwards, that needs to be monitored and if you haven’t recovered by the next day and you are still 4/10 pain then you are doing too much of the wrong thing for you at that stage. During each rehab session I ask people to repeat each exercise three times until fatigue with a minutes rest between sets.

Catching hip pain early and treating it aggressively before you pick up a poor movement pattern is essential for a speedy recovery. Do not leave things for a month before you do something about it. Early intervention is key in managing any injury.
So in summary, the devil is in the detail. We see many patients who make fantastic recoveries from severe hip pain with a huge amount of damage on a scan. The patients who do best are those who catch the pain early and make time to do the rehab properly and listen to their symptoms and don’t train with too much pain.

If in doubt and before you start doing the wrong thing it is important to get an accurate diagnosis. You should always get in to see an experienced physio or specialist sports medicine doctor with a special interest in the hip and groin as it is a specialist area and requires often a multi-centred approach.

If you would like further information or would like to send us a question please feel free to get in touch and we will help you as much as we can.

Douglas Jones
Director, Altius Healthcare
www.altiushealthcare.co.uk


wilstrop

Simon Redfern speaks to Professor Max Fehily about the hip operation he performed on world no.6 James Willstrop, his rehabilitation and the options available to the general public. Professor Max Fehily is one of the top sports hip surgeons in England – but when he operated on former world no.1 James Willstrop back in September 2017, the 31-year-old Yorkshireman was the first professional squash player to go under his knife.

While Professor Fehily has a particular interest in young athletes with soft-tissue hip problems and performs over 160 hip arthroscopy procedures a year, he mainly deals with footballers and rugby players from his base in Manchester.

“I treat a lot of English Institute of Sport athletes in the North, but most of the sportsmen I see are footballers or rugby players (of both codes) – or from Olympic sports such as taekwondo and athletics,” said the lead surgeon at the Manchester Hip Clinic.

Nevertheless, Willstrop’s condition – called femoro-acetabular impingement – is a familiar one to Professor Fehily. “His condition is very common in athletes, particularly male athletes, as they develop an abnormal bump on the ball of the hip,” he said.

“Every time it catches on the edge of the hip socket, it damages the rim. We believe it develops in early childhood and is a major cause of osteoarthritis in later years. It is why so many footballers and rugby players have hip replacements early. It is particularly common in these sports.
“The bony abnormality is half the problem; the other half is the hip getting into positions which cause pain because the patient is so active. Lots of people have the abnormality, but it’s not painful.” It was certainly painful for Willstrop, so much so that he was concerned about competing at the Commonwealth Games in Glasgow, but Professor Fehily eased those fears with an injection.
“That was very good, as it got him through the competition,” he said. “It calmed down the inflammation, but it was very much a temporary measure. It can be very useful for getting the pain under control – and enabling him to carry out his rehab – but really the only option for curing it was operating early and using keyhole surgery quickens the recovery.”

The injection allied to rehabilitation exercises helped the world no.6 to not only win two medals at the Glasgow Games – a silver in the singles and bronze in the men’s doubles – but also land his first PSA Tour title in 18 months at the China Open before he entered the operating theatre.
“When we went in using hip arthroscopy, he had damage to the joint surface of the hip, which we treated,” reported Professor Fehily. “Also, he had a torn cartilage which we repaired and treated the bone surface damage. Then we reshaped the ball of the hip, which made it nice and spherical.” Ahead of Willstrop were 6-8 weeks of rehabilitation comprising hip strengthening and flexibility exercises, and hydrotherapy.

“He started in the pool, as he was quite sore for the first couple of weeks, but moved on to range of movement exercises to improve flexibility and strengthen the hip, then straight-line running on the cross-trainer, sidestepping, twisting and turning,” said Professor Fehily. “He is doing well.”
The Irishman is optimistic that he has prolonged Willstrop’s illustrious career with his surgical intervention. “Hopefully the injury won’t affect his playing career,” he said. “The whole point is that by reshaping the ball of the hip we have prevented further damage. The important thing was to stop further damage and allow him to carry on playing.”

Generally though, Professor Fehily advises against the surgical route to cure a hip problem unless it is absolutely necessary. “You should have rehab with an experienced physio before you go anywhere near a surgeon,” he stressed. “Core stability and pelvic floor exercises are really important for athletes. Working on those areas will help a lot and they may find they don’t need to do anything else. You need to keep your core strong and your joint fitness strong.

“Also, warming up is very important – as is warming down. When you get older you have to make more of an effort to do those. As well as strengthening exercises, you should look at your footwear and whether you need insoles.”

A hip problem would first reveal itself with deep groin pain during exercise, which is made worse by squatting, and may be present on both sides. There may also be an associated deep click, which can be either due to a torn rim cartilage or, more commonly, an inflamed tendon running over the front of the hip. If the condition has been present for some time, there may also be inflammation of the tissues surrounding the hip, such as the outer hip, the groin muscles or inflammation of tendons in front of the hip.

Eventually, as the damage continues, the patient may begin to develop more arthritic symptoms, such as a dull ache in the groin and increasing stiffness. Hip-related pain is not always felt directly over the groin; it may also be felt on the outer aspect of the thigh, the buttock or travelling down the leg. Occasionally, the pain you feel in the hip may actually be the result of a problem in your back, a hernia or other diagnoses. “Go and see a good physio first and do all the rehab,” Professor Fehily advised. “If you are still having pain after eight weeks, you need to see someone who specialises in that area.” Patients then undergo specialised x-rays of the hip, as well as more complex scans, such as CT and MRI. These scans are used to confirm the soft-tissue damage and to accurately map out the bony deformity.

If there is an underlying bony abnormality and physiotherapy has not resolved the problem, then surgery is recommended. The aim is to correct the bony deformity before there is irreversible joint damage. This is usually done by hip arthroscopy (keyhole surgery) where the deformity is shaved back via two or three small incisions.

“Hip arthroscopy is highly specialised and technically difficult surgery but can achieve excellent results if carried out correctly and on the right patient,” said Professor Fehily. “One of the difficulties with keyhole hip surgery is that the joint is much deeper in the body, so access is more difficult and the operation usually involves shaving of both the tissues and the bone. unlike with knee arthroscopy. That’s why it takes longer to settle down.” Those who do not benefit include patients with significant hip arthritis, with severe childhood hip disease or with inflammatory hip disease.

Occasionally, the bony deformity may be so large that an adequate bony reshaping is not possible using keyhole surgical techniques. In those cases the operation is done using an open technique; in others the damage caused to the joint by the impingement may be so severe that the only reliable option is a joint replacement.

In general, a patient is likely to be sidelined for 2-3 months after surgery and he or she might be on crutches for 2-4 weeks depending on what work needs to be done.

“Professional athletes will tend to have their own physio and support network around them, as well as being generally fitter than average, so they will recover more quickly,” said Professor Fehily. “Members of the public may be back in action within 2-3 months, but it can take up to six months for everything to settle down. If you have done a lot of rehab before surgery, recovery will be quicker.
“Post-operative care should involve lots of physio, rehab, hydro and a range of movement exercises involving the hip, core and stability.”

That is where Willstrop is at now, with the aim of returning to action at the Tournament of Champions in New York in January.

I’ve got quite a love for that event and it’s well within the limits of my recovery time, so I’m going for it,” he said. There is no danger of Willstrop rushing back, though. “I will be happy to play squash again at all,” he reasoned. “I’m not taking having a big operation like this for granted, especially at 31. If I’m coming back, I’ll happily wait!”

*Following this article, James went on to win a Gold Medal at the 2018 Commonwealth Games and the British National title in 2020.



Who does this affect?
Labral tears usually occur in patients who have femero-acetabular impingement. These patients have either an abnormal bump on their femoral neck or an overhanging pelvic cup. In both these cases, the soft cartilaginous cup rim (labrum) gets damaged (figure 1) as the hip bends up. Initially the rim is simply peeled back but eventually it becomes torn and occasionally shredded. Patients are typically younger and very active, often taking part in sports such as running, kick-boxing, mountain biking and horse riding. Occasionally it can occur due to a severe and traumatic injury e.g. hip dislocation while playing rugby.

Symptoms
Patients with labral tears present with deep sharp groin pain, which may only occur on full hip bending. They may or may not be an associated deep click, which can be either due to the torn labrum, or more commonly, an inflamed tendon running over the front of the hip. If the condition has been present for some time, there may also be inflammation of the tissues surrounding the hip such as the outer hip (trochanteric bursitis), the groin muscles (adductor tendonitis) or infammation of tendons in front of the hip (sartorius tendonitis).

Investigations
All patients undergo specialised x-rays of the hip as well as more complex scans such as CT and Magnetic Resonance Arthrography (MRA). The MR arthrogram involves injecting dye into the hip joint prior to the scan. This allows identification of the torn cartilage. CT scans are used to accurately map out the bony deformity. This is very important when planning the surgery.

Non-surgical Treatment
Not everyone needs surgery so we initially treat patients with physiotherapy, painkillers, anti-inflammatory drugs and modification of activity. However, if they have a proven labral tear and physiotherapy has not cured their symptoms, then it is recommended that they undergo key-hole hip surgery (hip arthroscopy) first to address both the torn cartilage and bony abnormality, then undergo our specialist rehabilitation afterwards. A patient who has a painful hip and a proven tear is unlikely to settle without surgical intervention.

Surgical Treatment
The treatment of choice is hip arthroscopy. This allows access to both the true hip joint itself and the front of the femoral head where the bony abnormality is often located. Most patients do not have frank labral tears, rather the labrum is peeled back from the acetabular rim. In those patients where there is a gross tear, there is good evidence to show that patients do better long term if the tear is repaired. Occasionally the labrum is frayed and is simply debrided back until it is stable. Once that is carried out, the rest of the joint surfaces are inspected and treated as required. If the joint surface is damaged, it can be trimmed back if minor or if more severe, then specialist techniques can be carried out to encourage new cartilage growth, such as stem cell grafting.

If there is an underlying bony abnormality on either the femoral head or the bony pelvic cup, then that is also addressed at this stage. This is technically difficult surgery but can achieve excellent results if carried out correctly and on the right patient. Based on Professor Fehily’s own experience and that of the wider orthopaedic community, certain patients do not do well from hip arthroscopy e.g. patients with significant hip arthritis, patients with severe childhood hip disease (hip dysplasia) or patients with inflammatory hip disease (e.g. rheumatoid arthritis). Occasionally, the bony deformity may be so large that an adequate bony reshaping is not possible using key-hole surgical techniques. In these cases the operation is done using an open technique and the labral tear can be addressed at the same time. In some cases, the damage caused to the joint by the impingement may be so severe that the only reliable option is a joint replacement. However, all patients are different and advantages and disadvantages of the various treatment options can be discussed at the time of your consultation with Professor Fehily.


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They say prevention is better than cure and that is certainly true in hips! Having said that you can’t change your genetics. Some people have a certain shape to their hip which seems to predispose to early hip osteoarthritis. These ‘CAM’ and ‘Pincer’ shaped hips predispose to pinching (impingement) of the hip against its socket, leading to damaged cartilage and eventually arthritis. Hip Arthroscopy surgery can be used to reshape the hip and may prevent early arthritis progressing to advanced stages.

The most important modifiable risk factors for arthritis is your weight and activity level. Being even slightly overweight leads to increased load on the hip joint. Over time the hip can be squashed down and change shape permanently. The increased angle leads to more pinching and the hip wears down more quickly. Losing weight can slow the whole process down, and medication (like that from a medical marijuana dispensary) can help mitigate the pain. Other people have illnesses in childhood such as Hip Dysplasia (the hip and socket are too shallow, having not formed properly), Perthes disease (the blood supply to the hip gets cut off in childhood), or Slipped capital femoral epiphysis (the growth plate of the bone slips out of place). All of these conditions need to be spotted in childhood so something can be done about it and potentially prevent adult hip osteoarthritis.

Early hip OA is much easier to fix than advanced OA. Sometimes X-rays can miss the early features, MRI or CT scans are more reliable. If you are sure that you have hip or groin pain, but the X-ray is normal, you will need to speak to your doctor about a specialist opinion or scan, as well as medications. In the meantime, you could always try some water soluble cbd as a short-term method of pain relief. Once the scans come back, you will be able to talk to your doctor about long term solutions. Don’t suffer in silence! Medications can be a mix of common painkillers or stronger opiate-based painkillers, as well as the consumption of various medical cannabis strains that you could research more into by looking into a page similar to https://menu.old27lansing.com/store/old-27-wellness/menu, as an example.

Sometimes a steroid injection done under X-ray guidance can give temporary relief, and provide clarification around whether pain in the groin or buttock area is truly coming from the hip joint, however, they generally wear off after 2-3 months, so it is not a long-term option. Another alternative to steroid injections that have been known to offer short term, yet effective pain relief, are the taking of certain strains of medical marijuana. But only if it is legal to do so in your area. Places similar to Leaf2Go, (visit this website here) offer a choice of the best strains that can help with pain and other physical or mental ailments, but again, this may not be a long term solution. Other substances such as hyaluronic acid (an artificial version of your natural joint fluid) and PRP are also being used but need to be further evaluated to see if they have long-term benefit.

It is important to do regular strengthening exercise (such as core stability and pilates) and maintain a healthy weight, if hip pain is becoming intrusive, ask to see one of our specialists.

Dr Leon Creaney
www.sportandexercisemedicine.co.uk


The Manchester Hip Clinic is committed to helping all kinds of people with hip problems to be free from pain and often to resume near-normal levels of physical activity – even those who may have thought that such relief would never be possible.

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