APTA’s Current Concepts of the Hip

Author

Nathaniel Yomogida PT, DPT

Published

October 30, 2025

1

Resources

Clinical Practice Guidelines

Muscles

Deep Hip Stabilizers

Guarded Deep hip Stabilizers

  • Femoral head will be pushed forward and be passively resting on hip flexor tendons anteriorly

The long muscles will attempt to perform the job of stabilization. Long muscles such as sartorius, TFL, rectus femoris, hip flexors, and hamtrings. I think of this similar to dysfunctional deep neck flexors that result in overactive scalenes, upper trapezius, and levator scapulae.

Biomechanics

Function

Red Flags

“Medical concerns related to traumatic onset injuries include but are not limited to fractures, dislocations, tendon avulsions, and lower abdominal organ injury. Traumatic injuries that are accompanied by inability to bear weight, intolerance to joint movement, obvious disfigurement, extreme swelling, non-musculoskeletal symptoms, or extreme patient apprehension should be considered indicators for medical referral before initiating physical therapy intervention and even potentially before performing a comprehensive examination”1.

Pharmeceutical considerations

  • Corticosteroids associated with AVN and Hip fx
  • Fluoroquinolone is associated with hip tendinopathies

Evaluation

Subjective

  • Nature
  • Severity

Screening

  • Connective tissue disorders

Screening for Medical referral

  • systemic or septic related inflammation
  • table 5

Lumbopelvic

SIJ

Pelvic Floor

Functional Testing

GAIT

  • Trendelendberg Sign

Diagnosis

Start generally

Is it Intra- or Extra-articular?

Intraarticular

If it is intraarticular, is the condition nonarthritic or OA

Intraarticular non-arthritic

Divided into 2 categories based on MOI: FAI or microinstability

Note

hip joint microinstability can coexist with FAI and hip

Note

AOPT hip OA CPG17 for a detailed description of hip OA characteristics that will assist in differentiating the condition from FAIS1

ddx: Other differential diagnoses include femoral neck and pubic ramus stress fractures and iliopsoas muscle complex and bursa involvement1

Hip Osteoarthritis

Updated Cluster

  • Moderate anterior or lateral hip pain with weight bearing activities
  • Morning stiffness lasting less than 1 hour in duration
  • Hip internal rotation ROM <24° or hip internal rotation and flexion 15° less than the contralateral hip
  • Increased pain with passive hip IR
Note

Hip internal rotation <15° was modified to <24°

Treatment

B Project

  • Are they deep hip stabilizers or external rotators?
  • Prone Hip IR/ER arthrokinematic test
    • Symmetry
    • End feel
    • ROM
  • Palpate each deep hip stabilizer distal belly during rotation
  • deep hip stabilizer release
  • Functional test?
  • FAddER contract-relax
    • Therapist assisted
    • Self-stretch

Modalities

  • BFR

HEP

SmartPhrase

OA Cluster

OA Cluster

  • Moderate anterior or lateral hip pain with weight bearing activities
  • Morning stiffness lasting less than 1 hour in duration
  • Hip internal rotation ROM <24° or hip internal rotation and flexion 15° less than the contralateral hip
  • Increased pain with passive hip IR

Adductor Injuries

Hamstring Injuries

Key points

  • Prognosis
  • Prevention
    • Future hamstring injuries
    • Secondary Complications

Prognosis

Palpation test

Prevention of future injuries

Preventing Secondary Complications

  • Active SLUMP

Greater Trochanteric Pain Syndrome

Greater Trochanteric Pain Syndrome: lateral hip pain that may originate from numerous sources surrounding the greater trochanter1.

Population

Civilian

  • 40-60 years old
  • Female

Athletic

PathoMechanism

GTPS is theorized to be an overuse injury due to chronic movement dysfunction of Hip Adduction and IR1.

Poor eccentric control when loading into a hip

An attempt to create stability by sitting into passive structures such as IT band and glute tendons

Piriformis Syndrome

Piriformis Syndrome: Posterior hip pain that is present with or without sciatica due to sciatic nerve entrapment

Figure 1: Hip and Thigh Muscles5
Figure 2: Muscles of the gluteal and posterior femoral region6

Testing

Four clinical signs and symptoms were identified as the most common findings and can be present with or without sciatica:

  • Buttock pain
  • Pain with sitting
  • Tenderness near greater sciatic notch
  • Pain with maneuvers that cause tension of the piriformis
  • Active piriformis test
  • Seated piriformis test

Ischiofemoral impingement

CONDITIONS-SPECFIC EVIDENCE-BASED REHABILITATION CONCEPTS

FAI treatment

available body of literature is relatively small and of lower quality when compared to hip OA Clinical expertise and experience is even more valuable with this population.

“Patients that do not achieve satisfactory results from a structured course of rehabilitation may be candidates for surgical intervention. Typically, arthroscopic procedures are performed, or less commonly open procedures, to remove excessive bone from the femoral head-neck junction or acetabular rim and treatment of any associated joint injury such as labral tears”

Education and activity modification

  • Decrease aggravating activities to allow the patient to move out of the inflammatory stage of healing
  • Pair this with education
    • How long to limit activity
    • Why “Consider a temporary recommendation of strengthening in “protected” ranges by decreasing squat or lunge depth along with decreasing the amount of forward flexion that occurs with exercises such as the single leg Romanian deadlift”
Note

A suggested length of time for activity modifications is not established and would be expected to vary by severity of presentation and patient goals

Body Structure & Function

Addressing hip flexor muscle length issues should be prioritized as tightness of these structures can have a postural effect by increasing anterior pelvic tilt.

Functional training

  • Single-Leg Positions and Movements

Return to Play

There is not an established RTP criteria for this population.

  • stepdown
  • single leg squat
  • SEBT

Hip microinstability

Hip Microinstability: Symptoms related to Hypermobility of the hip joint1

Hip Dysplasia

Hip Dysplasia:1

Presentation

Often patients compensate for insufficient passive stability by maintianing a position of anterior pelvic tilt to maximize femoral head coverage1.

  • Look for associated Iliopsoas and rectus femoris muscle tightness1

Treatment

Hip dysplasia is an unstable hip with overly-lax or weakened capsuloligamentous structures1.

As a result, treatment should involve a similar approach to hip instability.

  • Protect structures from instability events
  • Address impairments
  • Optimize function
  • Prevention of OA

OA Prevention

Osteoarthritis

Hip Osteoarthritis:1

Treatment Dosage

Type Days Sets Reps
Resistance 2-3 3-4 8-12x
Stretching 2-3 2-4 10-30s
Aerobic 3-5 20-90min 55-90% HRmax

Aerobic Exercise

Aerobic exercise

5590% maximal heart rate 3-5 days per week for 20-90 minutes in the hip OA population

Minimize impact during aerobic exercise

  • Cycling
  • Elliptical machine
  • Swimming
  • Running
  • Tai-Chi
  • Yoga

Activity Modification

Reduce joint irritability - Avoid prolonged end-range positions - Particularly hip internal and external rotation - Avoiding sitting with legs crossed or in excessive flexion

Femoral Neck Stress Fracture

Femoral Neck Stress Fracture: ?var:ref-femoral-neck-stress-fracture.definition

Caution

  • Immediate weight bearing restriction to prevent further fracture progression or compromised bony stability
  • 6-8 weeks and up to 14weeks for complex patients with poorer prognosis

Prognosis

  • Uncomplicated

  • Complicated

  • Compression Sided

  • Tension sided

Poor Prognosis

  • Tension-sided
  • age?
  • >50% width of femoral nec

Weeks 0-8

  • NWB
  • OKC exercises to strengthen
Refer to Aquatic PT

Aquatic exercises can be used to achieve a therapeutic exercise volume while not jeopardizing healing osseous tissue

RTS

Uncomplicated compression side FNSFs and pubic rami stress fractures that are managed nonoperatively can typically return to running and athletic activity around 12 weeks after diagnosis

However, return-to-sport timeframes of up to 28 weeks have been reported for complicated, and slow-healing cases

Rehab

  • Gradual PT supervised return-to-running1
  • Glute Medius strengthening
  • Frontal Plane pelvic stabilization
  • Pelvic stability during loading

Tension-sided FNFS

Tension-sided patients have higher risk for displacement with weight bearing1. As a result, surgery with a percutaneous screw fixation is the recommended course of treatment

Surgical Management

  • Tension-sided FNFS
  • Patients with compression sided FNSFs that are greater than 50% of the width of the femoral neck are also considered candidates
  • If a fracture becomes displaced, surgery should be performed to mitigate the potential for adverse effects including postoperative AVN and fixation failure

Rehab

Week 0-6

  • NWB1

Week 7-12

  • PWB1

3-6mo

  • Return-to-sport can be achieved around 3-6 months after surgery but, can take up to a year in complicated cases with delayed healing1

Extra-Articular Conditions

Iliopsoas Complex Injuries

Activity modification

  • Minimize aggravating mechanical and pain symptoms
    • i.e. Repetitive hip flexion and extension

This can lead to substantial activity modifications for athletic populations

Successful activity modification

You must provide alternatives to the activities for the patient to maximize healing and minimize atrophy

  • Cardio: Cycling, ellipitcal, or aquatic exercise
  • Resistance training:

ROM

Stretching, STM, trigger point release, and dry needling were all recommended to improve ROM deficits1

No time restrictions were given based on acuity of injury.

Strengthening

  • Gradually progress strengthening
  • Since the psoas major and minor originate from the thoracolumbar junction, it is important to monitor lumbopelvic stability during exercises
  • Lumbopelvic strengthening and stabilization exercises are important to start early to create a stable foundation for the iliopsoas complex before exercising it
    • supine lumbopelvic stabilization → CKC lumbopelvic stabilization
  • marching in supine → Seated → Standing1
  • Apta recommended resisted hip flexion from 20° extension to 45° flexion
  • Loaded hip flexion with ankle weights, bands, and cables
    • Standing hip marches have changing torque on the hip, with the most torque at 90° hip flexion
    • Supine SLR exercise will have increased torque at 0° hip flexion with decreasing load as you approach 90°

RTS

  • ballistic speed exercises1

Criteria

  • Symptoms still reproducible
  • substantial strength asymmetries

Unresponsive to PT

  • US guided corticosteroids1
  • Endoscopic tendon release1
  • Lengthening procedures1

Adductor muscle injuries

Acute / Protective phase

  • gentle ROM at hips and knees1
  • Lumbopelvic stabilization1
  • Isometric activation of adjacent / unaffected muscles

Criteria

  • Tolerance of therex
  • Low-level ADLs
  • Symptom stability
Tip

Since patients are very irritable and limited acutely, they should be re-evaluated as their pain/functional tolerance increases to screen out coexisting conditions1

Subacute phase

Impairment based rehab

  • Flexibility exercises should only be employed when there is symptom stability thyroughout the available ROM
    • limited evidence for mm flexibility in prevention

Prevention

  • Adductor:Abductor Strength ratio: >80%1
    • Pro hockey had 17x increase risk of adductor mm injury if <80%

Strengthening

Isometric → Concentric → Eccentric

Limited → Full ROM

The Copenhagen 5-second adductor squeeze test1

Table 1
Pain Sport Readiness
0–2 Ready
3–5 Caution
6–10 Not Ready

Copenhagen Hip and Groin Outcome Score (HAGOS)

Hamstring injuries

Stage Goals Intervention Criteria for advancement
Acute phase
  • Pain and edema management
  • Prevent development of tissue adhesions
  • Limit atrophy and strength deficits
  • Limit flexibility and ROM deficits
  • Normalize gait pattern
  • Relative rest and avoidance of aggravating activities
  • Ice, compression, local electrophysical agents as indicated
  • Soft tissue mobilization
  • Active ROM and submaximal strengthening
  • Gait training
  • Symmetrical passive and active hip and knee ROM
  • Normal gait pattern
  • No reactive pain or symptoms with prescribed therapeutic exercises
Intermediate phase
  • Increase strength and muscular endurance
  • Regain preinjury flexibility
  • Restore lumbopelvic stability
  • Improve lower extremity neuromuscular control
  • Progress lower extremity and lumbopelvic strengthening
    • End-range & eccentric strength exercises 
          </li>
      <li>Stretching &amp; flexibility exercises</li>
      <li>Low intensity cardiovascular endurance exercises</li>
      <li>Single leg balance and neuromuscular control exercises</li>
    </ul>
  </td>
  <td>
    <ul>
      <li>Symmetrical flexibility and muscle length</li>
      <li>Symmetrical hamstring strength</li>
      <li>Adequate neuromuscular control</li>
      <li>Symmetrical jogging (if appropriate) pattern without reactive pain</li>
    </ul>
  </td>
</tr>
<tr>
  <td>Late phase</td>
  <td>
    <ul>
      <li>Return to all desired activities including sports or heavy manual labor</li>
      <li>Restore general and muscular endurance necessary for sport or other activity demands</li>
      <li>Identify and address modifiable factors for reinjury</li>
    </ul>
  </td>
  <td>
    <ul>
      <li>Strength and flexibility exercise progression
        <ul>
          <li>Emphasize lengthened state, eccentric strength, and higher velocity movements</li>
        </ul>
      </li>
      <li>Progress balance and neuromuscular control exercises
        <ul>
          <li>Perturbation training and reactive tasks</li>
        </ul>
      </li>
      <li>Sport-specific or work simulation training</li>
      <li>Plyometric and agility exercises as appropriate</li>
    </ul>
  </td>
  <td>
    <ul>
      <li>Full and pain-free hamstring strength at all muscle lengths</li>
      <li>Demonstrate tolerance to all sport or work specific tasks</li>
      <li>No apprehension on H-test if patient anticipates returning to high level sport participation</li>
    </ul>
  </td>
</tr>

Early phase

  • Reduce pain

  • Reduce edema

  • Protect further damage by minimizing load

  • Minimize atrophy

  • 3-4 Days of immobilization

  • Excessive mobilization can cause excessive scar formation

  • Use crutches

AD usage

  • Use if ambulation exacerbates pain
  • Foot flat > toe-touch or NWB

Limit Atrophy

  • Low-intensity & Pain-free ROM

  • Avoid isoalted hamstring exercises

  • Hip AROM

  • Knee AROM

  • Submaximal pain-free hamstring isometrics

  • Transverse Abdominis activation

  • Low-resistance stationary bicycling

  • Side-stepping

Progression Criteria

  • Normal gait pattern
  • Full hip A/PROM
  • Full knee A/PROM
  • Pain-free submaximal hamstring contraction

Intermediate phase

Goal: Progressive and restoration

  • Increase LE strength
  • Regain pre-injury muscular length
  • Improve lumbopelvic stability
  • Restore neuromuscular control

Stretching

Avoid Stretching

  • Significantly weak muscles
  • The muscle may be unable to protect itself

Eccentric strengthening

Criteria:

  • Good tolerance to rehabilitative exercises
  • >50% contralateral strength

Eccentric is important for rehabilitation and prevention

  • a 10-week eccentric hamstring strengthening program reduced 1st time injuries and recurrent injuries by ~85%1

Lumbopelvic stability should be included prior to sport-specific training

Sport-specific training

  • No proximal stability deficits

Late Stage

Criteria

  • Tolerance to all current therapeutic activities
  • Symmetrical hamstring flexibility
  • 5/5 manual muscle testing grade or 90% involved versus noninvolved side instrumented strength testing for hamstring muscle
  • No obvious balance deficits
  • No obvious neuromuscular control deficits
  • Ability to jog forward and backward at greater than 50% effort without symptoms

Gradually expose individual to sport/preinjury activities

Goals:

  • Muscle flexibility
  • Strength
  • Neuromuscular control
  • Endurance

Strength

  • Eccentric focus
    • increasing ROM
    • resistance
    • volume
  • Deadlifts
  • Single-leg Romanian Deadlifts
  • Nordic Hamstring Curls

Nordic hamstring curl

Van der horst found that nordic hamstring curls decreased rate of hamstring injuries in amateur soccer players1

Exercise progression

Monitor for symptoms:

  • Increase in soreness
  • exacerbation of symptoms

Exercises

  • Nordic Hamstring Curl

LEFS

Lower Extremity Functional Scale

References

1.
APTA. Current Concepts of Orthopaedic Physical Therapy. 5th ed.; 2024.
2.
Enseki KR, Bloom NJ, Harris-Hayes M, et al. Hip Pain and Movement Dysfunction Associated With Nonarthritic Hip Joint Pain: A Revision. The Journal of Orthopaedic and Sports Physical Therapy. 2023;53(7):CPG1-CPG70. doi:10.2519/jospt.2023.0302
3.
Cibulka MT, Bloom NJ, Enseki KR, Macdonald CW, Woehrle J, McDonough CM. Hip Pain and Mobility Deficits-Hip Osteoarthritis: Revision 2017. The Journal of Orthopaedic and Sports Physical Therapy. 2017;47(6):A1-A37. doi:10.2519/jospt.2017.0301
4.
Clinton SC, Newell A, Downey PA, Ferreira K. Pelvic Girdle Pain in the Antepartum Population: Physical Therapy Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Section on Women’s Health and the Orthopaedic Section of the American Physical Therapy Association. Journal of Women’s Health Physical Therapy. 2017;41(2):102-125. doi:10.1097/JWH.0000000000000081
5.
Betts JG, Blaker W. Openstax Anatomy and Physiology. 2nd ed. OpenStax; 2022. https://openstax.org/details/books/anatomy-and-physiology-2e/?Book%20details
6.
Gray H. Anatomy of the Human Body. 20th ed. (Lewis WH, ed.). Lea & Febiger; 1918. https://www.bartleby.com/107/

Citation

For attribution, please cite this work as:
Yomogida N, Kerstein C, Yomogida PT, DPT N. APTA’s Current Concepts of the Hip. Published October 30, 2025. https://yomokerst.com/Presentations/FHCSD/presentation_fhcsd_2025HipCurrentConcepts_page.html