Chronic Hip Flexor Pain

author : AMSSM

comments : 1

I had the physical therapist at my old college give me a rehabilitation plan. I just can't get the chronic tightness and pain to go away.

Member Question 

Let me preface this by saying that I have researched solutions. I had the physical therapist at my old college give me a rehabilitation plan. I stretch and do leg exercises such as leg lifts. I warm up and cool down properly. My shoes are a proper fit. I just can't get the chronic tightness and pain to go away.

The Back Story:

- In Sept/Oct of 2010, I pulled my hip flexor. It hurt to the point where I couldn't lift my knee more than 90 degrees. I ended up getting better in Dec/Jan of that Christmas Break, but it was still noticeably tight.

- About February of 2011, it got tweaked again. Same pain, just not quite as severe. Again, pain went away August of that year.

- Jan-June 2012, I went to Basic Training/AIT. No pain at all, but still a slight, but noticeable, tightness.

Now to present day. All semester so far up until about a week ago, I have had no hip flexor pain, but still the very noticeable tightness. I'm in the Army ROTC on the Ranger Challenge Team and I am training for a half marathon later this month. My mileage is getting to 7-8 mile normal runs and a few tempo runs and other speed workouts. I ran cross country from 2008 to 2010, so I am not new to distance running. In the ROTC Ranger Challenge, we do 4-7 mile ruck runs in boots and 35lb ruck. We did one this morning and it REALLY aggravated the flexor pain. I've been stretching to get it to go down, but I'm just worried like no other that it's going to develop into what it used to be.

I have never been frustrated this much with a running injury. I'm hoping I can get some great input.  Thanks.

Answer by George G.A. Pujalte, MD, CAQSM
Member AMSSM 

Hi Beginner Triathlete reader,

I am glad that you have looked for possible solutions. When you said that the physical therapist at your old college gave you a rehab plan, did he/she actually evaluate you? Or did he/she listen to your story of what you were feeling, concluded that, indeed, you were having a hip flexor strain, and then gave you exercises that are “usually effective” for hip flexor strain? I say this because chronic hip flexor strains are usually caused by a combination of problems, and it may not be a matter of “covering all bases” as you appear to have done, as it is addressing the main contributing causes. If you haven’t actually been evaluated formally by a physical therapist and an individualized regimen made for you, that may be the appropriate first step.

May I ask how you pulled your hip flexor around September 2010? The mechanism is important in the sense that the amount of force, the direction of the force, other aspects of the injury mechanism, may give clues as to what else could be going on that has been causing this chronic tightness that you continue to feel. Your initial inability to lift your knee up to more than 90 degrees suggests other possible injuries to the tendons or other structures around the groin area may have been present, injuries that would have been visible with ultrasound imaging, magnetic resonance imaging (MRI), or an MR arthrogram (where a dye is injected into your hip for better visualization of your labrum, the structure that covers your hip joint, and gets torn in some athletes). Even an x-ray may reveal, or at least rule out, a cause of chronic pain, such as early arthritis, avascular necrosis (a condition where the hip bones deteriorate usually from a lack of blood supply), or a stress reaction. Sometimes a “sports hernia” is revealed by the combination of history, physical exam, and imaging.

The fact that the pain goes away is reassuring. In fact, it points back to the possibility that a formal evaluation by a physical therapist who may create an individualized rehab plan for you may truly be the first step. This evaluation may need to include a running video that may reveal the factors leading to the “tweaking” episodes you get. That it is only a slight “tightness” at this time points to the possibility that this is indeed a hip flexor strain that will respond to an individualized rehab program, developed with a thorough physical exam and a videotaped running evaluation.

At this point, if you have already gone through a rehab program that has been individualized for you, and other bony possibilities have been ruled out with x-rays, an MR arthrogram may be appropriate to see if there is anything torn, or if there is a problem with your hip labrum.

As you may have noticed, there are a lot of questions with this input. That is because, in truth, pain that presents similar to a hip flexor strain is actually one of the more challenging presentations for sports physicians to evaluate. Without a thorough history and physical exam, there are a myriad of possibilities. If what you have is determined to be truly a hip flexor strain after a thorough evaluation, confirmed by advanced imaging, an individualized rehab program would still be the primary treatment. Some physicians do steroid injections, but this is controversial.  Surgery is only considered after all non-surgical treatments have been exhausted, if a tendon is found to be ruptured, and for hip labral tears, although this is controversial also. If what you have is truly a chronic hip flexor strain, some surgeons will consider doing procedures such as a “tenotomy,” where involved tendons are either divided or cut. Once again, though, surgical options for this condition are usually viewed as a last resort.  

Good luck!

George G.A. Pujalte, MD, CAQSM

Assistant Professor

Division of Sports Medicine

Departments of Family and Community Medicine, and Orthopaedics and Rehabilitation

Penn State Milton S. Hershey Medical Center

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date: January 24, 2013