What are the treatment options for hip pain with tilted hips?

Treatment for Hip Pain with Tilted Hips

Exercise-based physiotherapy for at least 3 months is the primary treatment for hip pain with pelvic asymmetry, focusing on hip and trunk strengthening to address the underlying biomechanical dysfunction. 1

Initial Conservative Management

Exercise-Based Treatment (First-Line)

• Implement a structured exercise program lasting a minimum of 3 months, as shorter durations (3-7 weeks) show significantly smaller treatment effects 1
• Include hip strengthening (particularly hip abductors and gluteus medius), trunk stabilization, and functional movement training to address the biomechanical imbalances causing pelvic tilt 1, 2
• Exercise prescription must specify load magnitude, repetitions, sets, time under tension, rest periods, and progression parameters 1
• If meaningful improvement is not observed after 6 weeks, reassess the diagnosis and treatment approach rather than continuing the same ineffective program 2

Adjunctive Conservative Measures

• Oral acetaminophen may be considered when not contraindicated for symptomatic relief 1
• Intra-articular corticosteroid injections could be considered if conservative measures fail 1
• Avoid intra-articular hyaluronic acid injections (strong recommendation against use) 1
• Avoid oral opioids for treatment 1

Monitoring and Patient Education

Required Outcome Tracking

• Use patient-reported outcome measures (PROMs) such as the Copenhagen Hip and Groin Outcome Score (HAGOS) or International Hip Outcome Tool (IHOT) to objectively monitor treatment response 1, 2
• Assess physical impairments (strength, range of motion, functional tasks) and psychosocial factors throughout treatment 1

Patient Education Components

• Discuss realistic expectations using shared decision-making 1
• Emphasize that pain does not necessarily correlate with structural damage 2
• Educate that the minimum treatment timeline is 3 months before determining effectiveness 2
• Encourage continued physical activity and sport participation as tolerated 1

Diagnostic Considerations for Pelvic Tilt

Common Causes Requiring Evaluation

• Intra-articular pathology: Femoroacetabular impingement, labral tears, or early osteoarthritis (most common in younger adults with gradual-onset symptoms) 3, 4
• Extra-articular causes: Greater trochanteric pain syndrome, gluteus medius tendinopathy, iliotibial band friction 3
• Structural abnormalities: Femoral or acetabular version abnormalities (present in 52% of symptomatic hips, with severe abnormalities in 17%) 5
• Referred pain: Lumbar spine pathology, deep gluteal syndrome 3

Imaging Approach

• Begin with plain radiographs of the hip and pelvis 3, 6
• If diagnosis remains uncertain after negative or equivocal radiographs, MRI of the hip without IV contrast is appropriate for evaluating soft tissue pathology 2, 6
• Ultrasound-guided anesthetic injections can help differentiate intra-articular from extra-articular pain sources 3

Surgical Considerations

Indications for Referral

• Failure of 3-6 months of appropriate conservative treatment 1, 2
• Confirmed structural abnormalities (femoroacetabular impingement, labral tears, gluteus medius tears) that typically have good surgical outcomes warrant early referral 3
• Physiotherapist-led rehabilitation after hip surgery should be undertaken if surgery is performed 1

Preoperative Optimization

• Optimize BMI if elevated (reduces adverse events and improves outcomes) 1
• Control diabetes (HbA1c optimization) if present 1
• Smoking cessation 1
• Wean off narcotic medications under physician guidance 1

Critical Pitfalls to Avoid

• Do not continue the same treatment approach beyond 6 weeks without documented functional improvement 2
• Exceeding evidence-based visit thresholds (approximately 14 visits for non-postoperative hip pain) without demonstrating meaningful progress represents overutilization 2
• Discontinuing exercise programs before 3 months leads to suboptimal outcomes 1, 7
• Failing to address specific impairments (hip muscle weakness, altered gait mechanics, balance deficits) with generic protocols results in persistent dysfunction 7