X-rays reveal much information as to why a patient has hip pain. Hip problems can also produce groin pain. The two most common causative findings on X-ray are unlevel femoral head heights (fhh) and/or one or both hips degenerated.
Maggs Law℠ of tissue tolerance states: When the loading of a tissue exceeds the capacity of that tissue, compensatory physiological changes occur. With the hip, unilateral or bilateral excessive loading almost always leads to premature degeneration.
Rapid degeneration of the hip joint can occur after trauma or because of repetitive microtraumas, which represents some combination of increased activity with abnormal loading of the joint.
Case history
Carol, 61, came into our office in February 2023 for right hip pain. While palpation and orthopedic testing may provide some clues as to why Carol hurts, no initial test is as valuable as the standing X-ray. Without it, no one can conclusively know the cause of Carol’s pain.
As part of our exam, we look at the full architecture of the patient, which includes considering the feet as the origin of the injury. Our feet are the first anatomical structures, which bear and withstand the ground reaction forces and, therefore, serve as the foundation and ground floor of the whole building. When addressing loading and abnormal loading, we must look at the human body as a living, running machine.1 When addressing abnormal loading, we must always begin with the feet.
In 2022, a study of 1,001 digital laser foot scans showed not only that everyone has some degree of foot collapse in one or more arches of the feet, but that the collapse ranges from moderate to total pronation (Fig. 1).
We can no longer look at our feet independently from the rest of the human kinetic chain. There is an intimate relationship between the feet and the alignment, balance and function of both the musculoskeletal and nervous systems.2 As seen in Carol’s foot scan (Fig. 2), there is an imbalance from right to left and her feet clearly show significant pronation. Therefore, to address the abnormal loading causing the hip pain, we must start with custom orthotics.
Custom orthotics will support the feet so they assume the optimal and symmetrical support that will begin the process of reducing abnormal loading of the hip(s).
A study published in 2020 demonstrates there are five different versions of Crooked Man℠ (Fig. 3), and the only way to learn which version a person is requires an A-P L-S X-ray while standing barefoot, followed by an A-P L-S X-ray with custom orthotics in shoes. This information will clearly demonstrate which Crooked Man a person is, and with each version, there are specific corrective measures that can be taken. The same study also refers to Maggs Law℠ of Tissue Tolerance: Whenever there is uneven loading, our body can adapt to some extent, altering the tension and biology of soft tissues (muscles and tendons) surrounding our joints. However, this barrier is frequently surpassed, and our muscles and tendons cannot withstand the continuous force and/or load applied and become injured.3
On Carol’s barefoot A-P L-S X-ray (Fig. 4), a story unfolds. Not only is the right femoral head 8.6 millimeters higher than the left, but there is significant degeneration of the right hip. This usually will produce a restricted range of motion as well as possible pain.
When custom orthotics were put into Carol’s shoes, we re-took the A-P L-S X-ray (Fig. 5). Her femoral head height difference (fhhd) increased to 9.3 mm. Since the difference was less than 1 mm from the barefoot X-ray but more than 3 mm in difference, Carol would be classified as a Crooked Man 5. A 7–mm lift was attached to the base of her left orthotic.
Six months after these x-rays were taken, Carol made another appointment in my office. She came in post-surgically, having a total right hip replacement. Carol wanted to know if her hips were now level as her surgeon told her it should be close enough but that’s not something they worry about. So, we re-took Carol’s A-P L-S x-ray with her custom orthotics on (Fig. 6),
Conclusion
Carol’s condition was not an overnight occurrence. Hip degeneration takes years to reach the level of Carol’s right hip. If Carol only visits an orthopedic surgeon, the options are hip replacement, a cortisone shot or a physical therapy referral. None of these options address the abnormal loading that contributed to Carol’s condition. The fact that her left hip has traveled the same miles her right hip has but there is no apparent degeneration in the left side cannot be overlooked. This provides solid evidence that abnormal loading is the primary contributor to premature degeneration, which our country suffers from on an epidemic level.
The fact is her fhhd was still greater than normal (making it abnormal) after her hip replacement and no tests in our health care system are routinely done to identify these imbalances. The 20-30 years Carol may have left in her life would be dramatically improved if the postsurgical goal was to balance fhh as much as possible. This could be done with the appropriately sized lift underneath the custom orthotic on the low femoral head side.
Another issue here is the subpar preoperative planning many surgeons do. People should not undergo joint replacement surgeries without having a complete understanding of fhhd, leg length difference and abnormal loading of the joint. Without the use of X-ray scans, adequate preoperative planning and post-operative follow-up are impossible.
DCs should be the experts both pre- and post-surgery. However, to be that expert, X-rays are mandatory. As long as our schools and national organizations continue to discourage young graduates from using X-ray as a primary diagnostic tool, and as long as practicing DCs continue saying “insurance won’t pay for them” and “people don’t want them,” our profession will continue to be compared to that of physical therapists and massage therapists, whose primary function is to relieve pain in the absence of knowing what’s causing it. To gain respect as a profession we must deserve it. This is one clear step in that direction. And, insurance does pay for X-rays and people do want them.
TIM MAGGS, DC, has been in full-time practice for 45 years. He traveled the country as a lecturer for 20 years, and continues today with his national lecturing, webinars and research studies. In the past three years, Maggs was the lead investigator on six medical peer–reviewed published studies and is excited to introduce his new Dr. Maggs℠ Feet First System. For more information, visit DrTimMaggs.com/Feet-First or contact him at DrT@DrTimMaggs.com.
ALEX SIOZOS, MD, is an orthopedic surgeon in private practice in Greece. Siozos specializes in hip replacements and is the coauthor of multiple research studies with Maggs.
References
- Maggs TD, et al. Are the biomechanics of the feet considered enough in their contributory relationship to leg length and femoral head height difference? Advanced technology provides new information. Ortho & Rheum Open Access J. 2021;17(5):555974.
- Maggs TD, et al. Each Person’s Collapse of the Arches of the Foot May Be Unique, but its Correction is Standard. A Large Study Explains Why. Ortho & Rheum Open Access J. 2023;21(4):556068.
- Maggs TD, et al. When correcting the collapse of arches of the feet with custom orthotics, are other areas of the body effected? A revolutionary approach towards reduced injuries and better outcomes. Ortho & Rheum Open Access J. 2020;17(1):555953.