Hip instability and problems with balance and falls in the older patient

Many people have concerns for themselves or they have concerns for an aging loved one concerning fall risks. These concerns surround a joint, or in the case of this article, a hip giving way. Many patients we see who have hip instability also have problems with the knee, spine, and pelvic pain. They will typically say to us, “My hip is the big problem, but I am falling apart all over.” These people are right, their hip is the big problem, but the hip problem is bigger than they think, the hip is causing problems all over the body.

One of the main treatments for hip instability of course is hip replacement. One of the main causes of hip instability is also hip replacement. If you search the current medical literature for recent papers on how to help people with hip instability, many of these papers deal with the problems facing some people after they have had hip replacement surgery.

One of the main reasons you are reading this article may be in looking for help in avoiding a hip replacement and what can realistically be done about hip instability.

Chronic hip instability – Is it fixed by surgery or is it caused by hip arthroscopic surgery?

Many people have a history of arthroscopic hip surgery. If you search the medical literature looking for research on hip instability, you will find dozens of new articles on hip instability after total hip replacement and hip arthroscopic surgery. You find very few on the role of ligament injury and damage before hip surgery. Yet it is pain and lack of motion caused by hip instability that sends patients to these hip surgeries. Based on the literature, one could get the idea, that hip instability can only be cured with surgery. This article will not come to that sole conclusion.

You are grabbing for a chair, railing, or anything you can hold onto. For some this happens after the surgery.

Hip instability to you means grabbing for a chair, railing, or anything you can hold onto. Medical research acknowledges these problems but seemingly in disproportionate awareness to patients before hip replacement and patients after hip replacement. The focus in research is on the patients after hip replacement.

Here is an example of the type of research that discusses hip instability, it is a recent study from the journal Knee Surgery, Sports Traumatology, Arthroscopy. (1)

“The increasing use of hip arthroscopy has led to further development in our understanding of hip anatomy and potential post-operative complications. Iatrogenic (surgery causing) gross hip instability following hip arthroscopy is a concerning complication described in the recent orthopaedic literature. Post-arthroscopy hip instability is thought to be multifactorial, related to a variety of patient, surgical and post-operative factors. . . This study reports a case of gross hip instability following hip arthroscopy, describing a (new surgical) technique of management through anterior hip capsuloligamentous reconstruction with Achilles tendon allograft.”

Did you get all that? Follow the path:

  1. The patient has hip pain and instability
  2. The patient is recommended to arthroscopic labral or other clean up and repair surgeries
  3. Doctors are using hip arthroscopy in increasing numbers
  4. The surgery that promised repair, stability, and relief of pain, itself caused instability and more pain. (Mostly from dislocation and chronic subluxation (the hip keeps popping out of place)).
  5. Because these hip problems happened infrequently or were reported infrequently, not much literature was given on solutions
  6. One solution was to come up with a surgery to fix the surgery.
  • These surgeries were designed to save the hip from hip replacement, but, to do so, the surgeries needed to halt or significantly slow the progression of osteoarthritis. As research points out, surgery many times will not achieve this goal.

The iliofemoral ligament

A July 2021 study in the EFORT (European Federation of National Associations of Orthopaedics and Traumatology) open reviews (x) analyzed previously reported studies on the role of the iliofemoral ligament as a hip joint stabilizer. Here are the observations of this paper:

  • The iliofemoral ligament is the largest hip ligament and plays a primary role in hip stability; in the case of hip dislocation, the iliofemoral ligament tear does not heal, resulting in a persistent anterior capsule defect. (Front of body injury and resulting instability)
  • Despite damage to this ligament that can because during hip surgery, the researchers suggested “different arthroscopic and open techniques have been described in order to preserve the iliofemoral ligament during surgery and, in case of lesions, several procedures with good to excellent results have been reported in the existing literature.”

In this image we see how injury to the iliofemoral ligament can lead to hip instability and the problem of Femoroacetabular impingement of the hip. This again is a diagnosis coming from hip instability.

In this image we see the role of the iliofemoral ligament in trochanteric bursitis. The iliofemoral ligament injury, whether it comes from acute injury or degenerative wear and tear leads to hip instability that causes the bursal sac to become inflamed by way of irritation being caused by the gluteus medius. This again is a diagnosis coming from hip instability.

Femoroacetabular impingement of the hip and the iliofemoral ligament.

Hip instability and problems with balance and falls. How a weak hip creates degenerative disc disease, degenerative knee disease, and degenerative pelvic disease.

Let’s look at a January 2018 study. (2) This study is an illustration of the damaging effects of one joint being wobbly on the entire movement of the whole body. Obviously, we will be looking at the hip as the culprit joint.

Women team handball players are amongst the fittest athletes. Their sport depends great stress on the player’s joints. The researchers from Auburn University, School of Kinesiology, Sports Medicine and Movement Laboratory examined how lumbopelvic-hip complex stability, via knee valgus, affects throwing kinematics (movement) during a team handball jump shot.

Read again how hip instability is being measured: the complex hip-spine-pelvic interaction and instability is being measured by knee angle. The greater the knee angle the greater the instability coming from the hip/spine.

Points to consider

  • The women with greater instability in the hip/spine/pelvic region through the ball with less force (they were weaker)
  • The women with greater instability in the hip/spine/pelvic region were at increased risk of injury in the upper (arm and shoulder) and lower extremities (knee, ankle, feet) when landing from a jump shot because of the energy losses throughout the kinetic chain and lack of utilization of the entire chain.
    • What does all that mean? Their entire body was at risk of fall, loss of balance, impact injury.

You do not need to be a high-level female team handball player to understand the problems in the hip cause and interact with instability in the lower spine and pelvis and these interactions put the knee, the ankle at risk for instability and loss of balance.

1 Yeung M, Khan M, Williams D, Ayeni OR. Anterior hip capsuloligamentous reconstruction with Achilles allograft following gross hip instability post-arthroscopy. Knee Surgery, Sports Traumatology, Arthroscopy. 2017 Jan 1;25(1):3-8. [Google Scholar]
2 Gilmer GG, Gascon SS, Oliver GD. Classification of lumbopelvic-hip complex instability on kinematics amongst female team handball athletes. Journal of science and medicine in sport. 2018 Aug 1;21(8):805-10. [Google Scholar]

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