CORRELATION BETWEEN HIP ROTATION DYSFUNCTION AND KNEE PAIN

ABSTRACT

BACKGROUND AND AIM

Hip and knee OA has been ranked as eleventh maximum contributor to global incapacity. The prevalence is expected to increase up to 25.9% by 2040. Hip arthritis reduces the mobility at the hip joint limiting flexion extension, abduction, and adduction, internal and external rotation. Similarly knee pain causes considerable disability among middle adult population affecting both proximal and distal joint (hip and ankle) respectively. Hence the present study aims to find out a correlation between Hip Rotation Dysfunction and Knee Pain.

METHODOLOGY

A cross sectional study was conducted on patient with hip and knee pain of age in between 45 to 60 years. Ranges at the level of hip joints were assessed using goniometer. Knee pain was assessed using Visual Analog Scale.

RESULT

The result obtained from the study shows a moderate negative correlation between knee pain and hip internal rotation, r= -0.67 showing no significant correlation p=0.45. There is also a weak negative correlation between knee pain and hip external rotation, r= -0.37 with a p> 0.05.

CONCLUSION

The result obtained from the study concluded that no significant co-relationship exist between hip rotation dysfunction and knee pain, however more researches with larger number of sample size is required to further evaluate the causal relationship between the two variables.

KEYWORDS

Hip rotation, Correlation, dysfunction, knee pain, VAS, Prevalence.

Batool Hassan

Physiotherapist

Sindh Govt. Hospital

Anum Haidar

Physiotherapist

Memon Medical Centre

Nida Kanwal

Physiotherapist

Maa Ayesha Clinic

Mehak Yaseen

Physiotherapist

Chiniot General Hospital

[Hassan B, Haidar A, Kanwal N, Yaseen M. Correlation between Hip Rotation Dysfunction and Knee Pain. Pak. j. rehabil.  2017;6(2):32-37]

INTRODUCTION

Hip and knee OA has been ranked as eleventh maximum contributor to global incapacity and 38^th maximum in incapacity Adjusted Life Years out of 291 conditions globally. Prevalence is seen higher in females than guys. Handicap for hip and knee extended from 10.5 million to 17.5 Million from 1990 to 20101. A research has been conducted in 2011 which revealed that around the world, osteoarthritis (OA) is presently evaluated to be the fourth driving reason for inability. The greater part of this inability trouble is inferable from the contribution of the hips or the knees².

An expected 52.5 million (22.7%) grown-ups in the United States have joint inflammation. Of those, 22.7 million (9.8% of U.S. grown-ups) have joint inflammation inferable action impediment according to Morbidity and Mortality Weekly Report 2016. The prevalence of arthritis is projected to increase 78.4 million (25.9% of U.S. adults) by 2040, and the number of adults with AAAL is projected to increase to 34.6 million (11.4% of U.S. adults).

Knee and hip osteoarthritis are profoundly common infections in the more established population. The estimation for hip substitution is by all accounts altogether higher than that for knee substitution. Out of 11,002 individuals, the assessed suitability rate for hip substitution seems 37.7% in men and 52.7% in women with osteoarthritis. The evaluated propriety rate for knee substitution seems 11.8% in men and 17.9% in women with osteoarthritis³.

Degenerative deformities at the joint leads to structural and functional limitations at the joint limiting its physiological movements.

Radiographic signs of Femoral acetabular impingement in asymptomatic adults with age in between 40 and 60 years shows increase in alpha angle is related to decrease internal rotation of hip joint leading to painful hip joint which may affect it’s proximal and distal joint (Sacroiliac and Knee) respectively⁴.

According to the American Academy of Orthopedic Surgeons knee pain is a common condition resulting in 19.4 million pain-related visits to a physician each year. This number is significantly higher than low back pain (5.9 million visits), hip pain (3.2 million visits), and ankle pain (1.9 million visits). Knee pain impairs function, which can lead to disability⁵. This condition is profoundly pervasive in more seasoned people and is viewed as an essential determinant of general wellbeing status in maturity⁶. Agony in weight bearing joints might be because of various causes, including alluded or emanated torment, sciatica, delicate tissue malady. In any case, confirm is developing that personal satisfaction and incapacity in OA are more identified with indications than to radiological seriousness⁷. Hip arthritis reduces the mobility at the hip joint limiting flexion extension, abduction, andadduction, internal and external rotation. Similarly knee pain causes considerable disability among middle adult population affecting both proximal and distal joint (hip and ankle) respectively. Patients with osteoarthritis are at higher danger of death contrasted and the all-inclusive community. History of diabetes, tumor, or cardiovascular infection and the nearness of strolling incapacity are real hazard factors. Administration of patients with osteoarthritis and strolling inability should concentrate on compelling treatment of cardiovascular hazard variables and comorbidities, and also on expanding physical action⁸.

If we need to examine a patient with complain of pain in knee joint, it is not completed without examining adjacent joint, hip and ankle, respectively⁹. There is a connection between power and position of hip joint and Patellofemoral Joint Stress (PFJS)10. It is revealed by a study that strengthening of hip abductor muscles was very much productive in mounting muscle power and diminishing pain in patients with Patellofemaoral Pain Syndrome (PFPS)¹¹.

The problem in the proximal (hip) joint can affect distal (tibiofemoral and patellofemoral) joint mechanics¹². Hip strength is very much significant. It is concluded that any movement at hip joint whether flexion, extension, rotation, poor motor control at the hip often manifests itself in knee pain¹³. Severe knee osteoarthritis is a strong cause of hip and knee pain¹⁴.

Loose or weak pelvis may contribute to knee injury. A strong upper leg strength can be beneficial in preventing knee injury¹⁵.The result of a study suggested that there is a strong relation between a weak hip and knee pain thus indicating a strong hip joint has a positive impact on distal knee joint and a weak hip joint may contribute to weaken the knee joint¹⁶. Periodic dislocation is seen in quite a few patients which give may arise to knee complications¹⁷. So the knee pain may have a direct or indirect relation with faulty biomechanics at hip and ankle joint¹⁸.

METHODOLOGY

Participants

Patients between age 45 to 60 years including both male and female.

Research Design

Cross sectional study design.

Study Setting

The research was conducted in Out Patient Department of Jinnah Hospital, Alamgir Health Care Center, Memon Medical Institute, Sindh Government Hospital.

Study Duration

6-8 months.

Sample Size

Sample size was calculated using WHO software for sample size calculation. The study conducted in 2010 title as “epidemiology of osteoarthritis” was taken to calculate the sample size. By taking the prevalence of hip OA 27%, keeping confidence Interval 95% and 8% bound of error; a sample size of 115 was calculated.

Sampling Method

Subjects were allocated to study groups using convenient sampling method.

Inclusion Criteria

• The vast majority of the consideration criteria

utilized were the understanding, capacity and readiness to partake in the outpatient technique¹⁹.

• Ranging from 45 to 80 years²⁰.
• Patients with both hip and knee pain
• Not taking any drug during the inclusion period which could perturb walking (for example neuroleptics)
• No limitation for strolling or light physical activity Exclusion Criteria
• Sign and symptoms of depression
• Any trauma and history of fall
• Grade 3 obese patients with BMI (>40kg/m2) will be excluded²¹.
• Patients with cardiovascular (e.g. heart disappointment, history of myocardial dead tissue, arrhythmia), pneumonic (e.g. embolism, respiratory disappointment) and inadequately controlled comorbidities will be prohibited²².
• Systemic problems
• Open wounds
• External fixators

Data collection procedure

All the subjects were recruited with knee pain; detailed hip assessment by a senior therapist was done. All ranges were assessed using goniometer and pain on the knee will be assessed using VAS.

Data Analysis

Analysis was performed by the researcher using computer analysis software SPSS Version ²¹. Descriptive data for the average of the three measurements VAS, IR and ER included means and standard deviations. The Pearson’s correlation coefficient was used to analyze the associations between hip and knee and to compare the pain of knee joint with hip

rotation dysfunction. In order to adjust for possible inflation of the (P > 0.05) alpha level due to multiple t-tests.

Outcome Measures

The visual analogue scale is a measurement tool which was used to assess intensity of pain which provides 0- 10 score in which higher score indicates high intensity of pain. VAS recommended score as no pain (0), mild pain (1 to 4), moderate pain (5 to 7) and severe pain (8 to 10). Another measurement instrument is goniometer which is used to measure ranges at hip joint.

RESULT

The study includes 100 participants with a mean age of 53.25. The male and female participants included in this study is shown in figure 1.

In the following table 1, the means and standard deviations of participants’ age s shown and gender distribution of participant. There were in total 100 participants in this research study were included. The demographics show that there was mean age 50 years. There were 24 % male and 66% female among participants.

Table1. Percentage distribution of demographic characteristics of knee pain patients
Demographic characteristics	n	%
Age (Mean±SD) years	53.25±4.5
Gender
Male	24	24
Female	66	66

With pain scale 4 mean IR=30.67 and ER=36, at pain scale 5 mean IR=32.88 and ER=34.52, at pain level 6 mean IR=27.77 and ER=30.06, at 7 mean IR=24.93 and ER=28.24 and at pain scale 8 mean IR=17.33 and ER=25 was found as shown in Figure 2.

Mean value for pain scale was 6.40 with the average IR found to be 26.21 and ER 29.64 of the given sample with the SD 6.49 and 8.03 respectively as shown in Table 2.

Table 2: Descriptive Statistics Of Pain Intensity (Vas), Internal Rotation And External Rotation (N=100)
Variable	Mean	Std. Deviation
VAS	6.40	1.03
IR	26.21	6.49
ER	29.64	6.49

There is a moderate negative correlation between knee pain and hip internal rotation, r= -0.67, p=0.45. There is also a weak negative correlation between knee pain and hip external rotation, r= -0.37, p= 0.13.

Table 3: Correlation Between Pain Intensity And Internal Rotation, Pain Intensity And External Rotation (N=100)
Variable	Pearson Correlation	P-Value
VAS+IR	-0.674	0.45
VAS+ER	-0.373	0.13

Correlation is significant at the 0.01 level (2-tailed).

DISCUSSION

The purposes of this study were to determine whether there are differences in lower-extremity kinematics and to examine the relationship between hip Rotation and knee pain. Correlation between hip rotation dysfunction and knee pain has been checked on patients who have pain in knee for more than 3 months. Results shows that patients who have severe pain have decrease internal rotation at hip joint as compare to the patients who have moderate pain. External rotation is also reduced to some extent but we don’t see any direct effect of knee joint pain on external rotation. As our interpretation of research there would be change in ranges depending on whether pain is moderate or severe.

There were no gender differences (P>0.05), which may be driven by the low subject numbers; however, due to the lack of gender differences, the correlational analyses were performed without regard to gender. Also, due to the moderate r-values reported for our significant findings, the results do not appear to be influenced by the low subject number.

Previous studies show a strong connection between hip and knee joint dysfunction that a faulty knee joint mechanics may influence hip joint function. According to Erik, When adduction or internal rotation increases at hip joint, it increases the Q angle by increasing the relative valgus of the lower limb, thus pressure on the patellofemoral joint increases due to peal lateral contact²³.

According to Gibson, pain and age of patient had inverse relation, younger patients report higher pain. Age difference in pain score have been reported but the cause of difference is not certain and questionable²⁴. Herr believe that older adults are not familiar with pain, cultural factor like stoicism results in under reporting of pain in older adults. Suggest that cultural factors, such as stoicism, lack of familiarity with verbal pain descriptors and the practice of pain reporting, may result in under-reporting of pain among older adults²⁵. Recently LaChapelle found that increasing age is related to decreased pain severity and the perception of greater control over pain. The literature suggests that under-reporting of pain by the older adult cohort may be commonplace and that older patients may perceive greater pain control and thus lower pain severity²⁶.

For the future studies, check range and pain scale before and after treatment to see whether ranges are consistent or increases as pain decreases after the treatment. Age group of patients should be specific.

CONCLUSION

VAS for knee pain is not a reliable tool to extract the exact condition of knee joint pain at that particular time and unequal numbers of males and females and low number of subjects who participated in this investigation were the limitations of the study. To ensure the correlational analyses were not influenced by gender, separate one‐way analyses of variance were performed to determine if there were significant differences between males and females for all variables of interest A final limitation of this investigation was the range of motion limits and positioning utilized for assessing Rotation of the hip joint.

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