Monday - Friday 09:00-16:00Saturday and Sunday - CLOSED+441614476762info@manchesterhipclinic.comSpire Hospital, 170 Barlow Moor Road, Didsbury, Manchester M20 2AF

Total hip replacement is one of the most successful operations that you can have. A successful one can literally be transformational. It can take a patient who is living with constant pain, dependent on strong pain killers, with very limited mobility and overnight, cure their pain and allow them to lead a fulfilling life. Because of the National Joint Registry, here in the UK, we can track patients after their surgery and see how long the implants last. We know that on average, if you have a well-designed implant (such as an Exeter), over 96% will still be in place and functioning well at 14 years. It is reasonable to predict that those implants will last 20 to 30 years. However, we know that if the components are not put in correctly or if the leg length or soft-tissue balance is not right, it can have a significant impact on the complication rate or how well the implant functions. This has led to the development of robotic hips.

mako surgical robot
Mako robot

Recently, some work has been done on what people are doing with their hip replacements after surgery. One paper published in 2019 showed that while all their patients returned to activity, there was a general move from high to low impact exercise. Another showed that after 10 years, 89% remained active but again there was a significant decrease in high impact sport. What is not clear is was that because patients were told to reduce their activity by their doctor/surgeon or was it because they themselves did not want to wear the new joint out? Perhaps by improving the accuracy of surgery and the muscle balance, we can have the confidence to enable people to maintain their desired level of activity?

The market leader by far in robotic assisted hip surgery is Stryker and the MAKO robot. They have well in excess of 500 machines around the world and over 40 in the UK. At the Manchester Hip Clinic and Spire Manchester, we started doing MAKO procedures in 2018 and are now the highest volume centre in the UK. Essentially, what MAKO does, is use CT scans to accurately map the shape of the patients own hip so that the new artificial one mirrors it exactly and then the robotic element ensures that the surgeon puts it in perfectly. Recent publications have shown that when using this technology, there is increased accuracy, improved patient function and quicker recovery.

computer planning for mako
Mako surgical planning

The use of MAKO has transformed how we do hip replacements. We see a lot of younger patients who have abnormally shaped hips that would previously have been very challenging to replace. With MAKO, we now have the confidence to know that we are choosing the correct implant and putting it in in the best possible position. That confidence allows us to encourage patients to return to sport and a range of different activities. If I was having a hip or knee replacement, I would definitely have it done using MAKO!

Understand more about MAKO…click HERE

Hear Oshors story…click HERE


Modern Hip resurfacing was introduced in 1997 by a Birmingham surgeon called Derek McMinn, who basically looked at two old prostheses, the Judet hip from the 1950s, and the McKee-Farrar metal-on-metal hip replacement of the 1960s and combined the two to make the modern hip resurfacing. It is still a hip replacement, but unlike “traditional” replacements, it consisted of a metal cup in the pelvis and a metal cap on the head of the thigh bone. It is sometimes referred to as a partial hip replacement but in reality, it is a complete hip replacement.

A resurfacing is a ‘metal-on-metal’ (MOM) implant. This refers to the two surfaces that rub against each other when the joint moves. Historically, for its time, the McKee-Farrar had very good survivorship, and so the idea was that metal bearings would last much longer than the other bearings of the time (metal-on-plastic or ceramic). Resurfacing tends to be more stable as the head which goes on the femur is very large, so the risk of ‘dislocation’ was less. This reduced wear and increased stability opened up the option of hip replacements to younger active patients, as the feeling at the time was that this type of implant would reduce the need for revision or repeat surgery, which is more complex, higher risk and likely to have a poorer result than a first-time replacement. What was not appreciated, was that the neck (which is much wider than the neck of a standard hip replacement) could still catch against the cup and cause damage, which is essentially what happens with hip impingement.

Significant numbers were implanted in the late 1990s and early 2000s. Other companies saw they were missing out and so all the major implant manufacturers released a version (but all had to be slightly different due to patents). The original Birmingham hip resurfacing has done the best of all the various versions but unfortunately, some of these new designs did very badly. Actually, compared with standard hip replacements, they all had worse long-term results. This was because the metal-on-metal bearing actually wasn’t as safe as thought. Back in the 1960s, patients were not as active as now, and were in much worse condition prior to their hip replacement (which at the time was considered ‘major’ surgery) and so the issues with MOM didn’t really occur. Over time, it became clear that while the resurfacing did not produce as much wear as the traditional types, it did produce large amounts of very small metal particles which could cause very significant soft-tissue reactions and damage.

The problems associated with the MOM bearing became apparent around 2006 and as a result most companies dropped it and versions of it around 2007-8. The numbers of replacements implanted in the UK fell significantly.


Numbers of hip replacements implanted in UK by type

The current scenario is that a lot of NHS and private hospitals will not allow any form of MOM hip replacements (resurfacing or otherwise) to be performed. There are a few surgeons who still perform them as they believe that the failure rate is associated with the implantation technique, which is true to an extent but not wholly so. This situation continued until Andy Murray had his resurfacing early last year, which led to an increase in interest once again.

Technology has moved on since 1997, there are now far better contemporary styles of hip replacement which have all of the benefits of a resurfacing without the downsides and so the indications for resurfacing over anything else have essentially gone away. We specialise in hip replacements (with ceramic on highly cross-linked polyethylene) using robotics as I believe that technology produces the best outcome with the least complications and longest survival. For comparison, the revision risk of the type of implants we use at 14 years ranges from 3.77 to 5.28% compared to 14.78% for all ages of resurfacings, which rises to 22% in those under 55 years (see NJR).

At the Manchester Hip Clinic, we use either Accolade 2 uncemented stems or Exeter cemented stems (depending on age or bone shape) with Tritanium cups, all of which are made by Stryker, one of the big global orthopaedic companies. The bearing surfaces are ceramic on polyethylene, which has the least wear and best long-term survival on the National Joint Registry and we use Mako robotics to make sure they go in perfectly which gives excellent muscle balance and allows early return to function.

Most patients are in 2-3 days and off crutches by 2-4 weeks, exercise bike by 2 weeks and gradual increase in activity over 6-12 weeks. The dislocation risk is highest until at least 12 weeks but the hip will continue to improve for 10-12 months post-surgery. The fitter and stronger you are pre-surgery has a big effect on your recovery afterwards. We treat a lot of high-level athletes for both arthroscopy and replacement, so we are very pro-active with rehabilitation. It is important for us to liaise with your physio locally so we can monitor your recovery. If that is not possible, we can arrange physio supervision over Skype with our own team or one of our partner practices.

For more information see our UK national guidelines, the national joint registry report

and some information on our website…click HERE


By Prof Max Fehily and Mr Giles Stafford, London Hip Surgeon (click HERE)


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)


Strength Core

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



(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


Spire Manchester


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


Both adults and children alike find that their level and intensity of exercise peaks and troughs throughout the year. The body has the most amazing capacity to adapt to any stress or load placed on it providing that it has time to do so. If we ask more of the body both bone and muscles can get stronger. The problems start when we have a sudden spike in a new activity or we do more sport at a greater intensity following a period of rest such as following the summer holidays and Christmas. When we then resume our sport with renewed vigor in a determination to regain any lost fitness the sudden spike in activity results in tissue overload and pain. Transitions between the sporting seasons such as the end of the football season and beginning of the cricket season pose problems with double the demand on the body. This is a particular issue with teenagers who are going through a growth spurt at the same time, which puts the muscles in more danger. Problems can occur in any part of the body, but back issues like spondylolisthesis caused by hyperextension of the back due to rigorous sports are common among teenagers. Luckily, such issues can be confronted by treatment from places like Medical City Kids Orthopedics, along with many other sports-related injuries faced by young or old athletes.

In growing athletes, there are two common types of overuse injuries, those affecting the bone and those affecting the insertion of the tendon on to the bone. Excessive, repetitive and sudden loading of young bones can cause bone bruising which often causes pain. With adequate rest, this will settle but if the symptoms are ignored, the child becomes at risk of a hairline fracture in the bone known as a stress fracture. These types of injuries tend to affect cricketers, swimmers and gymnasts who repeatedly arch their lower back stressing the bones in the lower back. They also are prevalent in the shin and foot bones especially in young runners. Recent thinking is that, in addition to excessive load there may also be a link to low levels of Vitamin D and it is worth considering supplementing the diet of children who live in northern England and those involved in indoor sports such as swimming and gymnastics.

In adults, we see many overuse injuries in tendons such as the rotator cuff tendon in the shoulder caused by a sudden spike in activities such as hedge cutting and is known as a tendinopathy. However, in children the area of bone where the tendon attaches to the bone is weaker than the tendon itself and loading the tendon in the same way results in a growth plate injury to the bone. These injuries are commonly found in the heel where the Achilles’ tendon attaches (Sever’s disease), the quadriceps attachment at the knee (Osgood Schlatters disease) and can occur in any area where muscles attach to young immature bones.

Traditionally the advice for overload injuries was rest. With careful management compete rest may not be necessary if the young athlete is given the correct early advice. There are guidelines within certain sports such as in cricket to limit the number of balls that young crickets can bowl in any one session and accumulated over the week. Many experts have used graphs such as this one to help us understand what is too much or too little (the “Goldilocks principle”) and it varies from child to child. The important factor is giving the growing body time to adapt and become stronger. The England Cricket Board adopt a recipe of no more than 2 consecutive days of fast bowling with no more than 4 days of play in every 7-day period.

This is a sensible approach to most sports giving the body a day to recover allowing minor stresses to be heal and repair and more tissue can be laid down in case the load recurs. Many young athletes can pack an enormous amount in to a week with some children doing several sports a day and no days off to repair. It is not only the muscles and bones in these very active children that are at risk. These children are often exhausted and susceptible to a condition called overtraining syndrome with recurrent sore throats and fatigue. Ensuring children get adequate sleep is paramount as this is when the body can repair.

The better conditioned a young athlete becomes, the stronger level of protection against injury. Learning to move correctly is critical to a child’s development and just like they must become literate in Maths and English, it is essential that they learn correct movement patterns and become physically literate. Movements such as lunging, crawling, squatting and deadlifts form the basis of many sports and should be taught at an early age but are often missing from the current physical education curriculum. Those movements would help people to use their bodies correctly, so they should really be taught. Alongside the correct movements, athletes should also be wearing the correct gear, such as Adidas training shoes. They should help people to protect their feet and ankles as they are designed for exercise. Before purchasing some of those shoes, people should also look at to try and find some coupons to save money. Hopefully, this will have a positive impact on athletes.

Physiofit specialises in the development of young athletes and can provide guidance on how to create strong and robust athletes who learn to monitor their workload and safely learn how to do age-appropriate strength and conditioning in a 1:1 or class environment in our rehabilitation centre in Wilmslow.

Angela Jackson MCSP AACP ACPSM –
Angela established Physiofit in 1992. She has been involved in treating people in sports at all levels both in the UK and Canada for the last 28 years. She has worked with the England Volleyball team, Cheshire Hockey, National league hockey clubs and is the Consultant Physio to all the Cheshire Cricket teams. Her major interest is in prevention of injuries especially in children. She now lectures on courses to share her expertise on developing athletes and gives regular talks in schools and clubs on injury prevention.
?She launched the Physiofit screening programme 20 years ago to identify how to prevent injuries and enhance performance and has helped many young athletes realise their sporting dreams in representing their country including her own two children. Her areas of expertise are in knee injuries, the sporty child, hockey, golf, running, cricket and nordic walking.
In the last few years she has become a dedicated running physio training with The Running School and with Blaise DuBois from the Running Clinic in Canada. She has extensive knowledge in golf strength and conditioning and screening having trained with TPI, Ramsay McMaster and Golf Biodynamics.

Who does this effect?
Hip arthritis in young patients occurs when there is degeneration in the hip causing damage to the joint surface (figures 1 and 2). There are numerous different causes but the most common is osteoarthritis. However, it can occur earlier due to abnormalities within the hip. This may be due to a previous injury, childhood hip disease, femero-acetabular impingement (A misshapen hip that catches and causes damage to the hip joint), or problems with the blood supply to the hip.

How does it present?
Commonly, this causes groin pain, often going down the thigh to the knee. The hip is stiff, and the patient walks with a limp. As arthritis becomes more widespread and severe, the pain becomes more constant, it may occur at night and be associated with increased stiffness, decreased mobility, and ability to exercise.

What investigations do you need?
X-rays of the hip to confirm the diagnosis are taken as standard. More complex scans such as CT or Magnetic Resonance may be needed to pin down the diagnosis and help surgical planning.

Non-surgical Treatment
To begin with, simple measures are tried such as painkillers, weight loss, and activity modification. Alternatively, some people have suggested the use of cbd isolate cream. Moreover, Oral supplements such as glucosamine and chondroitin may benefit some patients, especially with early arthritis. Injections such as steroid, hyaluronic acid or PRP may be used to either confirm the source of the pain (e.g. if the patient also has back pain) or in those patients who are not ready for a joint replacement.

When a patient has severe arthritis and painkillers no longer control the pain, hip joint replacement is advised. This has the benefit of relieving the pain and allowing the patient to return to a near-normal level of activity. If there is a waiting list for the surgery, patients will need help in curbing that pain for day-to-day living, this is where alternative medicines may be recommended. People who have suffered from pain have said that taking, herbal tablets, natural oils, CBD, medical marijuana, etc. have found relief from them. The latter has been lauded as one of the most brilliant ways of calming down pain and can be found on sites such as Before doing this, you must first speak to your doctor/consultant on how to go about this and if it is right for you to do.

In simple terms, the ball of the hip is removed and the thigh bone is prepared before the metal stem is inserted. The pelvic cup is then prepared and the artificial cup is inserted and held using either bone cement or an artificial coating that bonds directly to the surrounding bone surface (figures 3,4 and 5).

There are different forms of hip replacement and each one has a role to play depending on the patient’s age and activity level. Younger (<70) and more active patients, will have implants where the cup liner is made of a wear-resistant plastic and the ball of the hip will be made of ceramic, which is very smooth, hardwearing and produces less wear debris than traditional implants. Since 2018, we have pioneered the use of Robotics in hip replacement surgery. This allows for greater accuracy in positioning the implants and a faster recovery afterward. For more information about Mako robotic hips go to Robotic assisted hip replacement

As a sports physiotherapist I work in a number of diverse settings which gives me access to a wide range of clients from the elite professional footballer to the office worker who is a keen triathlete at the weekends. For each client the need is the same “how can I get the most out of my sporting hip and groin following injury in order to improve my performance.” Pain at the hip and groin region particularly can be very debilitating for the athlete, quite often it is very poorly understood area and as a consequence the problem can become chronic and result in an extended period on the sideline’s.

Diagnostics & Collaborative working
Diagnostics play an important role as the hip and groin is a very complex area and problems can be difficult to diagnose. Orthopaedic consultant opinion together with radiographic imaging and specialist reporting is important in pinning down the correct diagnosis. A collaborative approach in assessment from leading specialists in Sports Medicine and the Sports Physiotherapist is the most effective route in treating the athlete in terms of getting them back to action as soon as is safely possible and providing a solution to ensure their long term fitness.

Focused & Progressive Rehabilitation
First of all it is important to educate the athlete about their injury, the mechanism of injury often involving video analysis and the rehabilitation plan that will allow them to return to sport and avoid any injury reoccurrence. It requires a ‘buy in’ from both the therapist and the athlete to commit to a rehabilitation programme which will allow them to return to full fitness.
Hip and groin injury can be multifactorial in nature but it is important to focus targeted rehabilitation at the region initially and then progress to more dynamic loading as symptoms improve. I have found the following progressive stages of rehabilitation to be most effective within the sporting population:

  • Intersegmental control and strength (such as a deadlift or double leg squat)
  • Linear mechanics and running load (such as barbell/overhead running and leg change drills)
  • Multidirectional mechanics and sprinting (such as a lateral shuffle or Zig Zag cutting)

Within these 3 phases the therapist encourages correct execution in technique and correct lumbo-pelvic form. Furthermore, a gradual increase in load progression, speed intensity and multi-directional movement patterns is also encouraged. Other treatment methods may also be incorporated if deemed necessary, such as improving the mobility of the lower extremities and spine with manual therapy and sports yoga, application of strength and conditioning principles, Shockwave therapy and clinical Pilates.

It is also important to keep the athlete focused and interested within rehabilitation. In order to achieve this outcome the therapist must make rehab specific to their sport; jointly develop drills with the athlete to mirror scenarios encountered within a game situation and make rehab proprioceptively demanding in order to retrain reaction timing and load response.

Profiling & injury prevention
There is now a growing trend towards profiling of the athlete to highlight any injury risk factors and movement dysfunction that may predispose the athlete to injury.
A specific screening tool devised by the therapist specific to the demands of the sport and/or the athletes overall physical capabilities is generally used twice a year in both a squad environment or on an individual basis to measure athletic performance. The screen may broadly include the following battery of tests:

  • Range of motion eg. Shoulder mobility
  • Strength testing eg. Adductor Squeeze test
  • Balance testing eg. Single leg landing
  • Work Capacity testing eg. Push up to failure
  • Movement Patten analysis eg. Squat form
  • Outcome measure eg. Triple hop for distance

Data produced from the screen allows us to flag up any potential weaknesses that could be a contributing factor to injury and have an adverse effect on overall physical performance.
In order to nullify these weaknesses the athlete who presents as a high injury risk is given outlined bespoke action points to work on and then they are assessed more regularly, every few months throughout the year on key tests relevant to their profiling findings. This detailed monitoring allows us to prevent potential injury occurrence in key area’s such as the hip and groin and ensures the athlete remains fit, strong and pain free in order to achieve optimal performance.

Mike Kennedy MSc BSc (Hons) MHCPC MCSP MACPSEM

Manchester United Football Club Academy Physiotherapist
Lead Physiotherapist, Mike Kennedy Chartered Physiotherapy & Pilates
Highly Specialist Musculoskeletal & Sports Physiotherapist, Spire Perform Manchester
Consultant Physiotherapist to the Professional Footballers’ Association (PFA)
Associate Research Physiotherapist to the FASHIoN trial – Studying Hip Impingement

You can find more information on the services Mike provides at the following web resources:
Wigan Physiotherapy
Spire Healthcare


The demands on any sportsperson in the groin region is huge but particularly so in football given the volume of change of direction work involved. The fact that there are 45 muscles which attach to the pelvis in a variety of directions gives us a snap shot of the different forces involved in this region and why groin injuries are so common.

One thing that we used to frequently discover in football and the same in clinic now is that whenever people seemed to have pain or pathology in the hip and groin, there would be some kind of muscular weakness. There is strong evidence to suggest that reduced adductor strength is related to the incidence of groin pain and the development of groin injuries and yet people generally take the approach of stretching and releasing muscles (which may be relevant but not always) rather than combining this with a strength programme.

A nice simple way to strengthen your adductors can be to follow the “Copenhagen Protocol” which has been shown to significantly improve the strength in the adductors (even when performed during mid season competition). This would start with 2 sets of 6 in week 1 done twice per week and volume increase weekly very gradually. By 8 weeks you should be competent to perform 3 x 15 twice per week. To perform the exercise, adopt the position shown below and bring the lower leg towards your weight bearing leg and lower it back down again. If this is too hard then just hold the position to start the strengthening process.


This is of course only one dimension to a complex region of the body which quite often requires a more detailed assessment and rehabilitation programme.


Dave Williams, physiotherapist of Harris & Ross Physiotherapy at Wilmslow and Wigan clinics following 8 years working in elite sport at the Manchester City F.C Academy. During his time at MCFC, he was lead Physio for the hugely successful Youth team boasting players such as Phil Foden, Jadon Sancho and Kieran Trippier amongst many others.


Dr John Rogers MRCGP FFSEM(UK) – – Consultant in Sport & Exercise Medicine

Visiting Professor In SEM, Manchester Metropolitan University

Bone stress injuries and stress fractures are a common injury in track and distance runners and can cause significant loss of training time, often at crucial stages of the season. Stress fractures are defined as a partial or complete bone fracture that results from repeated application of a stress lower than the stress required in order to fracture the bone in a single loading. The annual incidence of stress fractures in track and field athletes is estimated to be 3.9 per 1000 hours of training with a prevalence of 76% and 10 – 20% of consultations in sports medicine are for stress fractures. It is important to diagnose stress fractures early so that they can be managed appropriately. If they are managed too conservatively this will result in unnecessary loss of training time and equally if higher risk stress fracture sites are not managed appropriately then they will not heal properly and it can take much longer for the athlete to return to running.

Stress fractures occur as a result of an overuse injury to bone. Sometimes they are due to fatigue within normal bone which is unable to adapt and repair quickly enough to cope with the repetitive biomechanical stresses and forces imposed through regular running. This can happen when runners build up their volume and intensity of training too quickly and is often seen when athletes return to training after a break.

The other reason why stress fractures occur is due to bone insufficiency or ‘weak bones’. In this situation, an athlete may have gradually built up their training over a 2-3 month period to a reasonable volume e.g. 40-50 miles per week. Due to underlying metabolic bone disease with low bone mineral density or osteoporosis, the structurally abnormal bone cannot adapt and repair itself to withstand the repetitive stresses and strains involved in normal training loads and this results in a stress fracture.

The commonest sites for stress fractures in runners are the tibial shaft (the shin), the navicular and the metatarsal bones in the foot. Other less common sites in runners include the femur (shaft and neck), sacrum, fibula, patella, talus, sesamoid, calcaneus, cuboid and the lower back.


A stress fracture should be considered in athletes with progressively worsening localised bone pain which comes on with running. It is important to look for risk factors for bone injury as described below. As things progress, the pain starts to come on earlier within training sessions and runs and the pain can persist after runs and during day to day activities such as walking. Sometimes pain in bed at night is a feature but this is not that common. It is important to know what volume of training the athlete is doing and how quickly this has been built up. There is often a sudden increase in volume or intensity of training with lack of rest days. The common risk factors should be asked about and examined for. A dietary history is important in male and female athletes and a menstrual history is very important in female athletes. Occasionally, there may be a family history of osteoporosis.

Clinical examination of athletes with a lower limb or pelvic stress fracture usually reveals localised bony pain on hopping and this is a useful screening test. There is often focal bony tenderness at a specific site. Pelvic, neck of femur and lower back stress fractures can be a bit more difficult to pick up on clinical examination but can be confirmed through imaging or speaking to pelvic therapy specialists. Early diagnosis through imaging helps to grade the bone stress injury, initiate appropriate management and minimise the time to return to running.


Magnetic resonance imaging (MRI) is the most sensitive and specific imaging modality for diagnosing stress fractures. It is important that the correct sequences are used to look for bone marrow oedema (STIR weighted sequence). MRI scans are also useful for excluding other soft tissue causes of localised pain. The other advantage of MRI is that it does not expose the patient to ionising radiation. There is a huge variation in the cost of paying privately for these scans and current rates vary from £195 to £500+. In most parts of the UK, it is difficult to get an MRI scan done quickly in the NHS for sports medicine related problems.

Plain x-rays (radiographs) are usually not that helpful although a discrete fracture line and/or reaction to the lining of the bone can sometimes be seen.

Radioisotope bone scans are sensitive for stress fractures but not specific i.e. they may also be positive in cases of infection, joint inflammation or cancer.

Computerised Tomography (CT) scans may be useful to establish the extent of a stress fracture and to plan surgery e.g. navicular stress fractures. A positive MRI scan but negative CT scan indicates a stress response which has a better prognosis.

Ultrasound Imaging may be useful in the diagnosis of metatarsal stress fractures where it can show a break in the cortex (lining) of the bone.

CT SPECT is a combination of CT and a nuclear imaging test where the images are superimposed on each other. It can be useful in some cases when the MRI scan is negative or inconclusive but the index of suspicion for stress fracture remains high.

DEXA scanning measures bone mineral density (BMD) and is an important investigation for screening athletes at risk of osteoporosis e.g. female athlete triad, stress fractures with a low volume of training, post menopausal runners with stress fracture, family history of osteoporosis. In athletes identified with low BMD (Z score < -1.0) and those with features of female athlete triad, DEXA scans should be repeated annually to see if the BMD is improving.

Blood testing for vitamin D status is important as if low this can delay healing and will increase the risk of further bone stress injuries. Vitamin K deficiency can be a risk factor for stress fractures but this is an expensive test and is not routinely tested for at first presentation. Other blood tests used to investigate amenorrhoea (no periods for >90 days) are thyroid function tests, prolactin, FSH, LH and oestradiol levels.

How are bone stress injuries graded?

Table 14



Bone Scan




Mild unicortical uptake

Positive STIR



Moderate unicortical uptake

Positive STIR and T2


Discrete Line

Acitivity in 50% of bone width

Positive T1 and T2


Fracture / Periosteal reaction

Bicortical uptake

Fracture line

Grades 1 to 3 are called stress reactions and grade 4 is a stress fracture. This distinction is important for management as stress reactions take less time to heal and the athlete can return to running several weeks sooner.

Who is at risk?

Table 23

Extrinsic (environmental)3

Intrinsic (to the athlete)

High mileage

External rotation of the lower limb

Inadequate recovery/rest periods and training with fatigued muscles

Bone anatomy: femoral anteversion, leg length difference, genu varum and valgum(bow legged and knock kneed), narrow tibia(shin)

Running Pace

Muscle: small calf girth

Hill running (particularly downhill)

Female sex

Harder training surface

Older age (>20)

Footwear (weak evidence that shoes play any role)

Poor nutrition, particularly low calcium intake and low overall energy intake


Previous bone stress injury

Aerobic fitness and sporting experience

Family history of bone stress injury or osteoporosis

Female Athlete Triad

Women with the ‘Female Athlete triad’ are especially at risk of bone stress injury. This condition affects many female endurance runners with low body weight/BMI. It consists of low energy availability with or without disordered eating, amenorrhoea (loss of regular menstruation/ no periods for >90 days) and low bone mineral density / osteoporosis. Athletes with disordered eating or conditions such as anorexia or bulimia need specialist medical input. For more information on this important condition have a look at this useful website:

Relative Energy Deficiency in Sport (RED-S)7

The RED-S concept has been adapted from a previously identified syndrome, the female athlete triad, which affects active women with low-energy availability, menstrual dysfunction and low bone mineral density. Emerging data suggest there may be a parallel syndrome in undernourished male athletes with resulting hypogonadotropic hypogonadism and impairment of bone health. RED-S is a comprehensive model depicting a low-energy status in physically active women or men. (Figure 6)


Stress fractures with a low risk of not healing properly can be managed conservatively in primary care (GP and a local physio) by stopping running. Table 2 outlines stress fractures at low and high risk of not healing properly (non union). The more serious the stress fracture the longer the athlete must rest the limb and depending on the pain they are experiencing, visit a PT service such as this LifeMotion Physical Therapy clinic or others. The general principle of managing low risk stress fractures is to offload from running for 6 to 8 weeks and then to slowly increase the volume of steady running. During this first 6 to 8 weeks athletes are usually safe to cross train to maintain cardio-respiratory fitness. Commonly used cross training modalities include:

  • Deep water running / aqua jogging (Figure 7)
  • Cycling
  • Swimming
  • Rowing
  • StairMaster
  • Cross-trainer (elliptical)
  • Nordic Ski

The rate of resumption of running will depend on the athlete and the symptoms but generally most runners will build back up to full training over the following 6 weeks (12 – 14 weeks from initial offload).

Table 3 Stress fractures at low and high risk of non-union3

Low risk of non-union

High risk of non-union

Femoral neck

(medial cortex – lower and inner border)

Femoral neck

(superior cortex – upper and outer border)

Tibial shaft (posteromedial cortex) –

Inside edge of shin

Tibial shaft (anterior cortex) –

Front of shin

Distal 2nd to 5th metatarsals

Proximal 2nd and 5th metatarsals




Proximal second metatarsal

Pubic Ramus



Medial malleolus

(inner bony prominence of ankle)



With stress reactions(as opposed to fractures) at low risk sites, the offload from running can be cut to 4 weeks followed by a gradual return to full training over the following 4-6 weeks. These time frames are a guide only and can vary significantly depending on any ongoing symptoms or lack thereof, the site and grade of bone stress injury, the athlete’s risk factors, personal circumstances / short term goals and availability of other rehabilitation facilities such as Alter G (figure 8) and underwater treadmills.

Pain can be managed by the use of simple analgesia such as paracetamol or cocodomol. Anti-inflammatory medication should be avoided as they can delay bone healing5. Sometimes crutches are needed for the first 1-2 weeks. Pneumatic bracing with an aircast boot, has been shown to reduce time to return to full activity in some lower limb stress fractures e.g. tibia6.

Modifiable risk factors need to be dealt with early to prevent recurrence e.g. vitamin D and calcium supplementation, optimise energy availability in female athlete triad, address any biomechanical factors and consider the need for orthotic prescription, appropriate strength and conditioning exercises are very important.

Stress fractures at high risk of non-union require specialist input with a sports physician and/or an orthopaedic surgeon.

Other treatment options sometimes used in elite athletes to expedite return in time for major competitions include the use of Bisphosphonate medication, Parathyroid Hormone, Strontium, Calcitonin, Exogen (pulsed ultrasound), Extracorporeal Shockwave Therapy (ESWT) and Hyperbaric Oxygen Therapy (HBOT). It should be stressed that the evidence base behind these interventions is still growing. They are expensive and some carry a significant risk of side effects. There is no substitute for offloading from running and allowing time for the body to heal itself naturally.


Prevention is always better than waiting until the injury or illness has occurred. Modifiable risk factors should be screened for and addressed. The commonest risk factors for stress fractures seen in UK based runners are vitamin D deficiency, inadequate calcium intake in the diet, low energy availability due to inadequate calorie intake to match calorie expenditure through training, low bone mineral density in female athletes with the female athlete triad, inadequate muscle strength/conditioning and a rapid progression of training volume and / or intensity without adequate time for recovery to allow bone to adapt.

Consider the following:

  • Speak to an experienced coach about your training schedule. This should involve a gradual progression of running volume and intensity over several months and years with annual periodisation of training. Recovery days need to be built into the weekly running schedule to allow bone time to adapt to the loads placed on it. This is especially important in younger athletes (<20) with an immature skeleton.
  • Ask your GP to check a vitamin D level twice a year in October/November and March/April time and if needed, taking high dose vitamin D3 supplementation if the level is less than 75nmol/L.
  • Take a daily vitamin D supplement e.g. 1000units Vitamin D3 daily
  • Aim to get 1200mg of calcium / day through your diet e.g. milk and other dairy products or through supplementation.
  • Discuss your daily calorie requirement and how to achieve this with a sports nutritionist. Aim for a Body Mass Index >19 kg/m2.
  • For female athletes who don’t have regular periods, you should ask your GP to arrange a DEXA scan to look for evidence of osteoporosis. This investigation is also important for male and female athletes who have had more than 1 stress fracture or who have other risk factors for osteoporosis. Where low bone density/osteoporosis is identified, you should be advised on management by your doctor.
  • In athletes with the female athlete triad, ideally seek out a consultation with a sports medicine doctor. There are now well over 100 specialists in Sport & Exercise Medicine working across the UK. In athletes with a possible eating disorder seek medical input early.
  • An appropriate weekly strength and conditioning programme to address core stability, gluteal control, quadriceps, hamstrings and calf muscle strength and endurance. This requires more than a weekly circuit training session. Multidirectional hopping (for as little as 2-3 mins daily) and appropriate loading for the lumbar spine and wrists is also important in preventing stress fractures and in optimising bone mineral density and bone architecture at these sites.


  • Bennell KL et al. The incidence and distribution of stress fractures in competitive track and field athletes. A 12 month prospective study. AJSM 1996;24:211-7
  • Kaeding CC et al. Management and return to play of stress fractures. CJSM 2005; 15:442-7
  • Pegrum J et al. Diagnosis and management of bone stress injuries of the lower limb in athletes. BMJ 2012; 344:e2511
  • Arendt EA et al. The use of MRI in the assessment and clinical management of stress reactions of bone in high performance athletes. Clin Sports Med 1997;16:291-306
  • Wheeler P, Batt M. Do Non Steroidal Anti-Inflammatory Drugs adversely affect stress fracture healing? BJSM 2005;39:65-69
  • Swenson et al. The effect of a pneumatic leg brace on return to play in athletes with tibial stress fractures. AJSM 1997 May-Jun;25(3):322-8.
  • Mountjoy M, Sundgot-Borgen J, Burke L, et al The IOC consensus statement: beyond the Female Athlete Triad-Relative Energy Deficiency in Sport (RED-S) Br J Sports Med 2014;48:491-497.

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.

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).

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.

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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