Hip Pain in Runners

author : AMSSM

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The focus of this article is on hip labral tears in runners. There are many causes and contributing factors to the development of a hip labral tear and treatment options are limited.

Member Question

The short version of the story is that I'm a 48 y/o male that had hip labrum repair and bone spur removed last June. I did my physical therapy and felt pretty good until December when my old symptoms started re-occuring (dull ache deep on left side of thigh, groin and butt). Increased activity (walking) increases discomfort, any lateral movement significantly increases discomfort. I went back to the ortho, got a hip injection with fluoroscopy. I had significant pain relief for about 1-1/2 weeks after injection, went back to the doctor and he sent me for an MRI. 

I got a copy of the MRI results and here are the findings; "There is borderline narrowing of the hip joint space. There is absence of a normal appearing anterior labrum. On the sagittal images, there is contrast extending adjacent to the anterior/superior articular surface where the labrum is expected and the appearance suggests tear. There is possibly some fibrillation and thinning of the articular cartilage at the medial joint." 

It doesn't sound good to me. Ortho is sending me for a round of PT and is talking about another surgery to try to clean things up. I've accepted that my Ironman days are probably over but I would still like to run and do shorter distance races if possible. Any thoughts? 

Answer by Troy Smurawa, MD
Member AMSSM 

Hip pain in runners is typically the result of the interactions of intrinsic and extrinsic factors that adversely affect hip anatomy resulting in hip injuries.  The etiology of hip pain in runners can be diagnostically as well as therapeutically challenging.  Muscle strains and tendonitis accounts for the majority of hip injuries in runners.  The most common involved muscles are the hamstrings, iliopsoas, rectus femoris and adductor muscles.  The proximal myotendinous junction of the biceps femoris is the most common site.  Iliotibial Band Syndrome is the most common cause of lateral knee pain in runners but can also cause proximal lateral hip pain.  Snapping hip syndrome is a benign condition but can cause pain as the iliopsoas tendon or ITB catches over the underlying bony prominences.  Trochanteric, ischial and iliopectineal bursitis are common overuse injuries in runners caused by increased friction secondary to biomechanics and anatomical malalignment. 

Stress fractures account for 10-20% of running injuries and 7-10% occur in the hip area.  Females are 3-10 times more likely than males to develop a stress fracture in the hip area.  Stress fractures typically occur in the femoral shaft, femoral neck, pubic rami, sacrum and iliac crest.  Osteoarthritis develops as a result of chronic wear and tear of the articular cartilage of the hip.  Often early osteoarthritis is associated with an underlying hip joint abnormality or a previous injury.  Acetabular labral tears are a less common but significant injury in runners that often requires surgical treatment.  Femoral Acetabular Impingement also leads to hip pain in runners and is often associated with hip labral pathology.

The focus of this article is on hip labral tears in runners.  The hip joint is a ball and socket joint enveloped in deep capsular tissue.  The acetabulum (socket) covers 170 degrees of the femoral head.  The acetabular labrum is a fibrocartilagenous structure the covers the rim of the socket.   The capsule and ligaments attach to the periphery of the labrum and stabilizes the hip.  The labrum provides secondary stability to the bony constrained hip joint.  The intact labrum has a sealant effect on the hip joint that maintains fluid for the articular cartilage.  The labrum also resists lateral and vertical motion of the femoral head within the acetabulum.   This control of motion is an important factor in maintaining hip stability during sports activities including running.

There are many causes and contributing factors to the development of a hip labral tear.  Hip labral tears can be either traumatic or degenerative.  Traumatic tears in athletes can occur from an isolated event such as an acute hip dislocation or an acetabular fracture or from repetitive trauma.  Degenerative hip labral tears result from wear and tear of the articular cartilage.  A high association between labral lesions and degenerative changes exists in that 74% of labral tears had co-existing chondral damage adjacent to the labral tear.  Femoral Acetabular Impingement (FAI) creates structural impingement leading to abnormal loading of the labrum and tearing.  Developmental abnormalities from congenital hip dysplasia as well as Slipped Capital Femoral Epiphysis and Perthes disease may lead to labral pathology secondary to abnormal contact of the labrum.  Hip instability and capsular laxity creates increase stress and repetitive micro trauma on the labral leading to tears.  Labral injuries in runners have been shown to be associated with subtle hip instability exacerbated by running leading to labral tears. Repetitive hyperextension seen in the stride phase of running leads to a subtle instability and increasing stress at the cartilage-labral junction.

Types of hip labral tears are characterized by their location and morphology.  Most hip labral tears in athletes are located anterior to superior.   The morphology of tears include radial flap, radial fibrillated, longitudinal, peripheral and unstable.  Runners tend to develop superior labral tears.  Many hip labral tears are associated with intra-articular injuries.  Chondral injuries are the most common lesions associated with labral tears.  The majority if pathological findings are found adjacent to the labral tear.  The chondral changes that develop include chondromalacia (softening of the cartilage), thinning of the cartilage, delamination of the cartilage, chondral flap tears and full thickness chondral injuries with exposed bone.  Ligamentum teres tears, synovitis and loose body are also found associated with labral tears. 

The treatment options for hip labral tears are limited.  Runners may try a brief trial of conservative treatment of limited weight-bearing with crutches, analgesics and activity modification for 4-6 weeks.  Physical therapy has not been found to be beneficial for the healing of the labral tear.  Most labral tears do not heal conservatively and incomplete healing increases the risk of chondral defects and osteoarthritis.  If conservative therapy fails, open or arthroscopic surgery may be performed to repair or debride the torn labral fragment.  Surgical repairs have excellent outcomes unless degenerative changes have already occurred.  Different treatment options may be beneficial to address degenerative changes affecting the chondral surface.  Physical therapy, a hip injection and surgical debridement are potential options.  Results vary depending on the extent and type of pathology.

Physical therapy is beneficial in treating post-operative labral repairs in preventing re-injuries and returning to pain-free running.   The focus of physical therapy is regaining hip range of motion, strength and stability.  The cornerstone of therapy in runners is to obtain core and trunk strength, stability and to gain the ability to maintain a neutral pelvic position and running posture.  Running biomechanics should be evaluated and addressed with the goal of achieving biomechanical running stability.   This may involve limiting hip impact forces, decreasing hip extension and decreasing anterior hip glide.  Gait re-training is helpful in correcting and changing running biomechanics to limit stress on the hip joint.  This often involves switching from a heel strike gait to a midfoot strike gait.  Controlling hip rotation and maintaining a neutral pelvic position through the running gait cycle is also important to achieve.  The potential for returning to running and the degree of running varies and depends upon the individual runner’s hip joint pathology and response to physical therapy and gait retraining.

Troy Smurawa, MD

References:

1. Guanche, CA and Sikka RS.  Acetabular Labbral Tears With Underlying Chondromalacia:  A possible Association With High-Level Running. Arthroscopy 2005; 21(5): 580-585.
2. Paluska, SA.  An Overview of Hip Injuries in Running.  Sports Med 2005; 35(11): 991-1014.
3. Bharam, s.  Labral Tears, Extra-articular Injuries, and Hip Arthroscopy in Athletes.  Clin Sports Med 2006; 25(2): 279-292.

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date: September 13, 2013