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

Treatment of Hip Pain with Tilted Hips

Exercise-based physiotherapy for at least 3 months is the primary treatment for hip pain with pelvic tilt abnormalities, focusing on progressive hip and trunk strengthening with specific attention to pelvic positioning during exercises. 1, 2

Understanding the Relationship Between Pelvic Tilt and Hip Pain

Hip pain associated with tilted hips (pelvic tilt abnormalities) commonly occurs in several conditions:

• Trochanteric pain syndrome (lateral hip pain) is frequently associated with pelvic tilt and gluteus medius weakness 2
• Femoroacetabular impingement (FAI) symptoms worsen with anterior pelvic tilt, which reduces hip internal rotation range before bony impingement occurs 3
• Hip dysplasia and acetabular version abnormalities are present in 52% of symptomatic hip patients, with severe abnormalities in 17% 4

The key insight is that posterior pelvic tilt increases impingement-free range of motion, while anterior pelvic tilt causes earlier impingement and pain 3. This makes pelvic motor control training essential.

Primary Treatment: Exercise-Based Physiotherapy

Program Duration and Structure

• Minimum 3 months duration is required for optimal outcomes, with programs shorter than 3 months showing suboptimal results 1, 2
• At least 12 supervised sessions are necessary, as directly supervised programs demonstrate superior pain reduction and functional improvement 2
• Treatment should not be interrupted before 3 months, as this is a common error leading to treatment failure 2

Specific Exercise Components

Progressive hip strengthening with emphasis on:

• Gluteus medius strengthening as the cornerstone, since this muscle controls pelvic tilt during single-leg activities 2
• Hip and pelvis motor control exercises, particularly in single-leg support positions 2
• Trunk strengthening to improve lumbopelvic stability 1

Exercise prescription must specify 1, 2:

• Load magnitude and progression
• Number of repetitions and sets (typically 3 sets of 8-12 repetitions for strengthening)
• Duration of contractile element and time under tension
• Rest periods between repetitions (30-90 seconds) and sessions (48 hours for same muscle groups)
• Range of motion parameters

Pelvic Positioning Strategies

• Teach posterior pelvic tilt during exercises, as this increases impingement-free range of motion by an average of 8° of internal rotation 3
• Combine hip abduction with posterior pelvic tilt for maximum benefit—this combination increases internal rotation by 8-9° compared to neutral positioning 3
• Avoid anterior pelvic tilt positions during high-flexion activities, as this causes earlier impingement 3

Patient Education and Expectation Management

Critical discussions to have 1, 2:

• Pain does not necessarily correlate with structural damage—morphological findings are common in asymptomatic individuals 2
• Realistic timeline: meaningful improvement requires 3 months, not weeks 1, 2
• Complete rest is contraindicated, as it leads to muscle weakness and joint stiffness 2, 5
• Strategic rest periods between exercise sessions are appropriate for recovery 2

Monitoring Treatment Response

Use patient-reported outcome measures (PROMs) at baseline, 6 weeks, and 3 months 1, 2:

• Copenhagen Hip and Groin Outcome Score (HAGOS)
• International Hip Outcome Tool (IHOT)

If no favorable outcomes after 6 weeks, reassess rather than continuing the same approach 6. This may indicate need for imaging or alternative diagnosis.

Additional Interventions

When Exercise Alone Is Insufficient

• Local corticosteroid injections at the greater trochanter can be considered for trochanteric pain syndrome with stable pain despite NSAIDs, with resolution rates of 49-100% 2
• NSAIDs are the most supported pharmacological option for hip osteoarthritis if present 7
• Weight management if BMI is elevated, as this reduces mechanical stress on the hip joint 5

What NOT to Do

• Avoid passive interventions (massage, ultrasound, heat) as primary treatment—these should not replace active exercise 2
• Do not push through severe pain during exercise, as this exacerbates inflammation 5
• Avoid prolonged inactivity or complete rest, which worsens functional outcomes 2, 5

When to Consider Advanced Imaging or Referral

Obtain imaging if 6, 8:

• No improvement after 3 months of appropriate exercise therapy
• Suspicion of structural abnormalities (FAI, labral tears, dysplasia)
• MRI hip without contrast is appropriate for suspected extra-articular soft tissue pathology 6

Early referral may be warranted for conditions with good surgical outcomes: FAI with labral tears, gluteus medius tendon tears, or severe acetabular dysplasia 8.

Common Pitfalls to Avoid

• Prescribing exercise programs shorter than 3 months 2
• Failing to include supervised sessions (minimum 12) 2
• Not addressing pelvic motor control and positioning 2, 3
• Continuing ineffective treatment beyond 6 weeks without reassessment 6
• Recommending complete rest instead of modified activity 2, 5