Member Case Study: Hip Pain

author : AMSSM

comments : 0

During a "power yoga" session I noticed pain with hip adduction/internal rotation. Running and biking don't seem to bother it, as long as I don't push it. I still have achy pain with walking.

Question from jchughes66

Hi. I'm a typical physician, trying to treat myself before having to resort to my regular doc. I'm a 41-year old, overweight, relatively new triathlete; just started running about a year ago. During a "power yoga" session (i.e. over-exuberant yoga stretch for someone over 40; it took until the second session for me to realize what was making me sore), I noticed pain with hip adduction/internal rotation.

I also ride horses (jumping), and after taking off 2 weeks from running/cycling, I realized what activities were exacerbating it (horseback riding). I've taken a total of 6 weeks off (4 weeks running/biking and 2 weeks horseback riding), and occasionally still have achy pain with walking/sitting.

Running and biking don't seem to bother it, as long as I don't push it. At what point do I need to have further evaluation, versus ice and NSAIDs?

Answer from  Andrew Hunt, MD

Member AMSSM

If I may summarize your complaint, it sounds like you are getting hip pain with end range of motion in internal rotation and adduction that began with some aggressive yoga exercises and persists with activities such as horseback riding and walking/running. Given just that information, I would consider several possible problems. The first one would be symptomatic hip arthritis, especially with your history of being overweight and your relatively new activity level over the last year. The second could be either a labral tear in your hip and/or symptomatic impingement (femoro-acetabular impingement), as your pain is worse with internal rotation/adduction. The other top choice on my list would be a possible groin/adductor strain, as this all began in yoga. Much lower down on that list, but still on the list, would be symptomatic degenerative lumbar disc disease at L4-5 or possibly L3-4 with radiation to the hip groin region.

The next step would be to get more information. A good physical exam focusing on hip range of motion and any secondary symptom exacerbation as well as a lower extremity neurologic exam to determine strength/sensation would be in order. At the same time, I would absolutely get plain X-rays of both of your hips and an AP/Lat of your lumbar spine (to look at disc space heights). Depending on those results, you may consider further imaging (MRI, MRI arthrogram) if the exam and plain films weren’t conclusive.

As for the timing of any further evaluation, my advice would be to do it now. If you were to be diagnosed with mild hip arthritis, you could easily adjust your activities to avoid making the pain worse. Whether that was backing off on running/impact activity or simply avoiding problematic yoga exercise, the bottom line is that adjusting your demands on an arthritic joint are more effective earlier rather than later. If the feeling after a physical exam is that your pain was from a labral tear or impingement, it might be correctable or at least improved with hip arthroscopy. A symptomatic lumbar disc issue is a longer story, but at least initially, the management would be conservative with anti-inflammatories and therapy. A groin strain/adductor strain should improve with physical therapy and core strengthening.

It sounds like you did all the right things initially consisting of backing off any predictably exacerbating activities, using ice, and taking anti-inflammatory medication. The next step really depends on what is seen on exam. In the meantime, keep the training regimen in the pain-free zone in regards to that hip/groin. Hope all of this helps!

Andrew Hunt, MD
Medical Director, USA Triathlon
Illinois Bone & Joint Institute-Sports Medicine; Glenview/Wilmette, IL
 

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date: May 12, 2008