Hip & Knee issues affecting Walking & Hiking.
Mr Andrew Hughes

Good evening. Andrew Hughes is my name, hip and knee surgeon from UPMC Sports Surgery Clinic, many thanks for the opportunity to speak to you this evening on hip and knee pain in hill walking and hiking. Hikers get hip and knee pain from mechanical overload of their hip and knee structures due to repetitive loading stresses of the tendons, the cartilage, and the joints in the hip and the knee. Uneven terrain demands stability from the hip and knee muscles. Unfortunately, something as small as an inadequate warm-up or an unlucky step can put a hiker or a hill walker at risk of injury. Forces walking uphill versus downhill differ. Walking uphill, there’s a particular pinch on the structures at the front of the hip joint, there’s friction between the iliotibial band, the large fascia on the outside of your thigh, and the bursa on the side of your hip joint and the load goes through the knee quite extensively from a flexed or bent position as you bring yourself up the hill. Going downhill, four to eight times your body weight can go through your kneecap or your patellofemoral joint. These forces peak as your heel touches the ground or the heel strike component of your gate cycle and the quadriceps muscles are lengthening but also contracting at the same time. We call it an eccentric contraction, and this controls your descent. Unfortunately, eccentric loading of a muscle or a tendon puts it at risk of injury. The tendons and cartilage around the hip and knee joints can succumb to overuse injury mechanisms whereby the load exceeds the tissue’s capacity to heal from repetitive micro traumas. These micro traumas can accumulate particularly if there’s insufficient recovery between a hike between hikes or a particularly long hike. Weak muscles can also transfer stress to otherwise passive structures and put these areas of succumbing to these micro traumatic episodes.

It’s important when you have pain around the hip or the knee to understand what we as physicians or surgeons look at to determine what the cause of the pain is. So, some of the terminology we use is lateral which means the outside of the hip, the thigh, the knee, medial which would be along the inside or kind of radiating from the groin, anterior is at the front, posterior is at the back. And then often times to distinguish to distinguish between particular pathologies or injuries, we want to know is the is the pain focal, is it pinpoint or is it diffuse? Is it over a wider area? And this can help us distinguish particularly from bursitis versus an Iliotibial band syndrome which I’ll come to shortly. So, pain in the groin could be Femoroacetabular impingement or arthritis in the hip joint, pain in the lateral hip could be gluteal tendinopathy or inflammation of the tendons in the outside of the hip or it could be bursitis which is inflammation of the shock absorber. Pain radiating down the lateral thigh into the lateral knee could be iliotibial band syndrome which is often associated with gluteal tendinopathy and or bursitis, pain at the front of the knee could be patellofemoral pain syndrome or an issue with the back of the kneecap. Pain below the kneecap can be patellar tendinitis where there’s an inflammation of the tendon where it attaches to the underside of the patella. Medial or inside the knee or kind of diffuse knee pain could be related to knee arthritis that’s come on over time.

So, the common hip problems that affect hikers most notably could be femoroacetabular impingement which arises from abnormal contact between the ball and the socket within the hip joint. So, you might hear terms like a pincer lesion or a calm lesion or mixed impingement, and these can be seen in the diagram on the right-hand side. This can cause groin pain especially on inclines or after prolonged activity that involve hip flexion. So, bringing your knee up over your hip, you can be stiff after rest or stiff in the mornings, you can have discomfort with prolonged sitting as you sits in a seated position with your knees up. This imping bone can lie in contact with each other either on the ball side of the socket side of the joint and cause a deep-seated groin discomfort and there can be clicking or catching within the hip or the hip joint or the groin particularly if the liberum is torn which is the shock absorber within the hip. Diagnosing an FAI really involves a clinical examination with a physician or a surgeon or your GP. X-rays are the gold standard of investigation to see are there abnormal bone and an MRI to look at the cartilage in the liberum in the hip. I would advise seeking  help if you have sharp pain in your groin that persists despite rest and the treatment involves activity modification, avoiding hip flexion, physiotherapy to strengthen your hip and your core, improving the strength of the rotators deep within your hip, working on improving the lateral control of the hip or the gluteal tendon strength around your hip. A hip injection of either corticosteroid or platelet rich plasma can reduce inflammation, improve the ability of micro tears to heal, and allow you to engage your rehabilitation pain free. If all conservative options fail, then you may benefit from hip arthroscopic surgery or a camera surgery where we go into the joint with long fine instruments, shave down the abnormal bone that’s causing issues and repair the labium.

Glutaeal tendinopathy or gluteal tendinitis is inflammation or irritation or degeneration of the hip tendons on the outer or lateral aspect of the femur. The pain is on the lateral side of your hip. It can worsen on stairs or hills and if you have coexisting bursitis, you can have pain lying on that side at night. Weakness or discomfort can also be noticed when standing on one leg and you can feel unstable or as if you’re about to fall when you are walking, particularly coming downhill if you have gluteal tendinopathy. Again, it’s a clinical diagnosis, but that would need to be confirmed with either an ultrasound or usually an MRI of the affected hip. I would advise seeking help if walking or climbing stairs is particularly difficult and if the pain progresses such that it it’s affecting your sleep quality, particularly when lying on that affected side treatment, physiotherapy is highly effective. I would advise avoiding crossing your legs or sidelining on the affected hip to reduce the amount of pain that you’re experiencing. A graduated strengthening program with a physiotherapist, progressive hip strengthening particularly sidelining leg lifts and single leg stance progression as per the guidance of a chartered physiotherapist.

Greater trochanteric bursitis then can be inflammation of the fluid fil cushion or the shock absorber on the outer side of the hipbone which lies in close proximity to the gluteal tendons. So this really gives you that point tenderness on the outside or lateral aspect of your hip. It can be a constant dull ache. It can really affect when affect your pain levels and increase if you lie on that affected side. And it often coexists with tendonitis of the gluteal or abductor tendons plus or minus iliotibial band tightness because that can push the greater tricentric bursa in against the bone as you walk. Diagnosis for greater trochanteric bursitis is clinical examination. It’s your point tender over that particular spot. And again, that can be that can be diagnosed further or confirmed with ultrasound or more commonly an MRI in these days. Again, I would recommend seeking help if climbing stairs is particularly difficult and if you’re having trouble sleeping as you cannot lie on the affected side. I would rest, ice, and take anti-inflammatories for greater trochanteric bursitis. Physiotherapy to progressively start loading the gluteal tendons which will take the pressure off the greater trochanteric bursitis and a corticosteroid injection or a steroid injection into that site of maximal tenderness can be very helpful if the pain is severe.

If gluteal tendinopathy and GT bursitis coexist, a progressive load-based physiotherapies rehabilitation program can be very effective, and platelet rich plasma injections have been shown to encourage healing of the micro tears within the tendon and encourage all of this to settle down. Iliotibial band syndrome then is tightness of this big fascia band that runs down the lateral side of your knee, and this can push the greater trochanteric bursa against the bone and really inflame your bursa as you’re walking. You can get sharp lateral hip thigh knee pain during repetitive hip flexion or bending of the hip. The pain typically starts after a consistent distance every time, but again that can start to worsen as that distance comes down with progression. You would be worse on hilly sections due to repetitive hip flexion. It’s particularly common in trail runners and you can feel a click or a clunk of your iliotibial band as it moves over the side of your hip. This is a clinical diagnosis. There are provocative tests that can prove that iliotibial band syndrome exists within your anatomy and stretching this or foam rolling the iliotibial band can be very effective. Then progressing to hip abductor or gluteal strengthening with clamshells or side planks. Retain retraining the gate so that your gluteal tendons are more fired and more turned on during the gate cycle. Modifying your activities until you really regain this strength and then gradual return to hiking particularly a hiking distance.

So, building up slowly once again. Hip osteoarthritis is cartilage wear causing bone on bone contact which can result in morning stiffness which improves at movement, pain in the groin after prolonged activity particularly walking similar to FAI or femoroacetabular impingement, difficulty getting down to do your own shoes and socks and needing to back into a low car seat because the actual movement in your hip is affected. This is a clinical diagnosis with X-rays. Treatment is weight optimisation in the first instance to reduce the amount of force going through your hips, gluteal strengthening with a physiotherapist and anti-inflammatory medications, injections or a hip replacement for advanced disease. And these have been shown to have excellent success. A total hip replacement would have you 90% recovered at 90 days. And we would hope to have you returning to hill walking or hiking with no restrictions after about three or four months of recovery and rehabilitation with a physiotherapist. With regards to the knee, patellofemoral pain syndrome is pain around the kneecap and it’s due to how the knee tracks within its groove. So, the kneecap or the patella moves within the trochlear groove at the bottom of the femur and how it always wants to go on the outside of the lateral side. And if this is the case, you can get pain at the front of the knee particularly when walking downhill as four to eight times your body weight can go through your kneecap when you are walking downhill. You can have pain with prolonged sitting or as the Americans call it the cinema sign or the movie theatre sign. So, after a prolonged period of sitting you feel like you have to shift in the seat in order to relieve yourself of this discomfort at the front of your knee. You can feel a grinding or a clicking sensation in the knee as it bends and straightens. My action plan would be to avoid steep descents when hill walking. If you have patellofemoral pain syndrome, consider trekking poles to reduce the load going through your knee. Warm up. Focus on your quadricep strength and ice the knee after activity. This is a clinical diagnosis. MRI can be considered if persistent, the treatment would be to improve how the kneecap tracks within the groove. So, strengthening the quadriceps on the inside of your knee.

The VMO is the quarter of the quadriceps that’s on the inside of the knee. And this can improve how your patella moves within the groove, improve its tracking, and hopefully reduce the patellofemoral pain that you’re experiencing. You can tape the patella or brace it to encourage it to track more immediately or more towards the inside of the knee. And if you’re having persistent problems, I would recommend a biomechanical assessment and a footwear review as the as there are multiple factors that can contribute to how your kneecap tracks. A corticosteroid injection can be very beneficial to reduce the inflammation and allow you to re reintroduce rehabilitation and strengthening exercises when the knee is calmed down.

Patellar tendinitis is inflammation on the underside of the tendon where the patellar tendon attaches to the kneecap or the at the top of the tendon. So, this is pain on the very underside of the kneecap worse with activity. You can be stiff or uncomfortable first thing in the morning in particular. You can get a sharp pain at the start of a hike on the underside of the kneecap where the tendon attaches. However, this eases as you warm up and then return slowly. Tenderness is also reproducible when your doctor presses on the underside of your kneecap or you or your physiotherapist press on the underside of the kneecap and really hit that that sore spot where the micro tears of the tendons are. It’s a clinical diagnosis which can be confirmed again using ultrasound or more commonly MRI these days. Treatment I would recommend rest and applying ice to allow the inflammation to come down, an eccentric strengthening program. So, it’s a strength and stretch program combined. So it’s very important to link in with the physiotherapist and patellar tendon strapping can reduce the amount of force going through the tendon particularly during hill walking and hiking activities. The exercises that a physiotherapist would probably introduce would be wall sits at 60° and progressing to 90 degrees with an increasing number on seconds per set. Progressive loading with single leg declining squats and gradual returning to your impact activities.

Knee osteoarthritis again like hip osteoarthritis is cartilage wear causing bone on bone friction morning stiffness pain within the knee globally after prolonged activity particularly walking and also swelling and reduced range of motion that can come on slowly. Knee arthritis is a clinical assessment which will be proved or confirmed using x-rays and the treatment again will be weight optimisation to reduce the force going through your knee. Physiotherapy to strengthen your quadriceps, non-steroidal anti-inflammatories, corticosteroid injections or platelet rich plasma injections or a knee replacement if the disease is advanced like in this x-ray. Again, similar to a total hip replacement, I would expect somebody to be 90% recovered at 90 days after a total knee replacement and after three or four months of rehabilitation, return it to hill walking or returning to hiking with no restrictions. There are essential habits that can protect your joint and function as prevention strategies.

I suppose the key principles are to progress your mileage roughly 10% weekly increase as you take uphill walking or hiking or returning from injury. Trekking poles particularly in the knee can reduce the load going through your knee joint by 25%. Proper footwear with adequate support can reduce the stresses going through the inside of your knee or the outside of the hip. And maintaining a healthy body weight again can reduce the amount of force going through your hip or your knee joints. I would recommend incorporating a warm-up routine into your hill walking or hiking. 5 to 10 minutes at the start. Roughly 5 minutes of level walking or light jogging in the car park before starting on the hill walk or the incline. Ankle circles, knee pull-ups, and hip rotations. So, 15 ankle circles in each direction to wake up the ligaments in the ankle on both sides. Knee pull-ups to work your hip flexors, your knee flexors, and your knee extensors, your quadriceps. And then hip rotations to wake up your gluteal tendons and your deep hip rotations, your deep hip rotators, doing 10 in each direction. So, 10 external rotation and 10 internal rotations. I would then do some dynamic stretches, some walking lunges, some high knees, some leg swings forward and back, and some calf raises, calf raises. And again, this is to increase the blood flow going through your gluteal tendons, going through your quadriceps, going through your calf, and just improving the vascularity of your soft tissues before you start on a hill walk or a hike.

Cooling down then afterwards for 10 minutes is very important. So, slowing down your walking to bring down your heart rate slowly. Standing and stretching your quadriceps for 30 minutes each. Stretching your hamstrings. So, bending forward and touching your toes for 30 seconds on each leg, calf stretching against a tree or a rock again for 30 seconds each. So, strengthen your quads, stretch your hamstrings, and stretch your calves. With regards to your hip and your iliotibial band, if you are engaged in a in a rehabilitation program for these specifically, I recommend stretching your hip flexor, which is a kneeling lunge and pushing your knee forward, stretching your iliotibial band, where you bring your affected knee over your the knee on the other side, and you feel a deep stretch going down the outside of your thigh. And a figure four glute stretch, particularly if you need to stretch the deep hip external rotators at the back of the hip. But these are more specialised or niche stretches. If these have been prescribed to you by a physiotherapist, I would seek medical attention for any of the above if the pain persists beyond about four weeks of rest or activity modification.

It takes about four to six weeks for soft tissues to settle down. So I would recommend rest and activity modification if you do have a flare of tendonitis or bursitis. If you cannot wake bear due to the pain, if the swelling comes on quite rapidly, if you feel like your joint is unstable or you’re at risk of falling, and if you’ve persistent pain at night or difficulty sleeping. One thing I did want to say with regards to joint replacement surgery is that it is a reliably successful option for bone-on-bone arthritis, which unfortunately is becoming more common as we live longer, and the capabilities of the medical services continue to improve internationally. You can return to hill walking, hiking or any sport after roughly four to six months depending on the level of impact. There is novel techniques and technologies to aid in surgical accuracy and improve recovery. Implant longevity or how long implants are lasting improves year on year. It was initially thought that knee replacements or hip replacements lasted between 15 or 20 years depending on how much activity you put through them. However, the newer generations of implants are really exceeding our expectations and the implants that have gone in between 2005 and 2010 are not coming back loose.

So, the honest answer is we don’t know how long the newer generation of implants are lasting. We’re doing hip replacements through the direct anterior approach where we go in through the front of the hip. It’s muscle sparing, It passes between two nerves. We can do X-rays within the actual surgery itself and ensure that the hip replacement goes in at 100% of an accurate position. We’re now using robotic assistance to do our total knee replacements. Again, ensuring that these are more accurate. We’re using cementless or no cement in knee replacement so that your bone grows onto the implant and this becomes one with your bone and as a result hopefully would never need to be revised. Physiotherapy is always a great first line treatment and there’s an increasing menu of injections available, platelet rich plasma, hyaluronic acid, corticosteroids. I would not recommend exploring stem cell injections just because the evidence is still quite limited and they can be quite expensive, but physiotherapy and injections are fantastic. And there’s no need to be afraid or apprehensive about your function after a total knee replacement or a total hip replacement because these are improving year on year. So, thank you very much for your time this evening and I’ll be delighted to take any questions.

It really depends on your joint, on your knee or on your hip. In the hip what the what the poles do it stops your pelvis from tilting. So it helps your gluteal tendons or the tendons on the side of the pelvis so that they have to do less work to keep your pelvis stable as you’re walking down the hill. So they’re very beneficial in the in the in the hip setting. In the knee setting it’s about reducing the amount of force going through the kneecap. I said it was four to eight times your body weight that can go through your kneecap as you’re descending a hill or stairs. So the poles will just reduce the amount of weight or the amount of force going through your kneecap. In terms of using them versus not using them if you have good strength and dynamic stability in your knee, the recommendation will be to, you know, not use the poles because you want to keep your knees nice and strong. But if you do have some changes on your X-rays or any inflammation on your MRI, then the purpose of the poles will be to offload those tendons and muscles that are affected. So, it’s kind of hard to say is there an age cut off, it really just depends on the status of your knee or of your hip. And but if you have any discomfort or any issues or any instability episodes, I would strongly recommend them. In terms of where to get them, I’m not entirely sure of if there’s a brand specifically that that would be recommended, but going into a shop like one of the hiking shops 53 degrees north or Decathlon and just speaking to somebody, feeling what feels good in your hands, feeling what what’s nice and ergonomic, what’s a good height for you, get them appropriately sized. It’s more having the support rather than a particular type of brand or a particular type of material.

Very good question. So, the older generations of hip and knee replacements we thought lasted kind of 15 to 20 years. However the newer generation of hip and knee replacements, we don’t entirely know how long they’re lasting because they’ve kind of gone in in the late noughties around 2005 to 2010. And they haven’t come back loose or worn to the same degree that we’ve seen the older generation of implants. This is because how the ceramic is engineered, how the plastic is engineered, how the titanium implants grow onto the bone. We’re not using cement as often. So there’s multiple factors and multiple developments that have contributed to hip and knee replacements lasting a lot longer. The technology and techniques we’re using going in through the front x-raying hips using robotic assistance for knees that all contributes to hopefully the longevity of the implants as well to the best of our knowledge. In terms of getting back to general exercise, it’s usually the kind of first four weeks or so is getting back on your feet. So, coming off your crutches, the second four weeks kind of getting your range of motion back and the third four weeks kind of focusing on your strength and your power. So anywhere between three and four months, you should really feel that you turn that corner and hopefully you can get back to some general exercise.

Ober’s test OB or test, so, if you bring your knee across your other knee and you get that tightness down the outside of your thigh that really is diagnostic that your iliotibial band is tight and that pushes your greater trochanteric bursa against the bone and that that bursa is really interconnected quite closely with where your tendon attaches. So that entire lateral hip complex can be inflamed. So, strengthening your glutes, stretching your iliotibial band, that’ll really help your gluteal tendons, help your iliotibial band and take the pressure off your bursa. So whilst a gluteal tendon based program is very beneficial, stretching the iliotibial band will really take the pressure off the burst as well.

Yes. And yes, unfortunately it really when you when you do see a physiotherapist and really make kind of strides or progress in the right direction, it’s about maintaining that progress. And I always tell people in the clinic that the most important time to stay on top of your rehabilitation and stay on top of your physiotherapy exercises is when you’re strong and when you’re relatively pain free to prevent a flare. That goes for back pain. That goes for gluteal tendinopathy. That goes for knee arthritis. It’s really about working these exercises into your daily into your daily routine. So first thing in the morning or lasting at night.