Desperate with Hip Injury

author : AMSSM

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Of all the major joints, the hip joint remains the most difficult to evaluate for most orthopedic and sports medicine clinicians.

Member Question

Over the years, I still have never learned proper form or used safe or reliable training programs. I got minor injuries but nothing some ice and rest couldn't heal. I was young and bounced back fast. 

I've since done three marathons and countless other distance races. For a few years I did triathlons, completed four sprints and seven Olympic distances. Again, I never really followed any program. I would just go out and run. 

HOWEVER, let's fast forward to April of 2014. 

I'm 40 and running here and there, nothing consistent. I start to feel some aching in my right hip, but I push through it like I always have. A few weeks of this ache and I decided to shut it down and heal. I rest and treat it like I've treated all my running injuries over the years. But this time, it's different. No relief and it increased in pain. 

So what have I been through since last April? 

Orthopedic #1 has MRI that shows gluteus max/minimus tears, tendinitis, and bursitis. Gives me injection (that gives zero relief) and recommends PT. I do PT for four months. Very little-to-no relief of symptoms. 

Orthopedic #2 recommends surgery to remove bursa, ITB release, and repair glutes. I refuse. 

#3 Supposedly well respected Sports Orthopedic here in Denver.  I wait three months for appointment and I just told to rest six weeks. Grrrrr...

#4 Podiatrist recommends orthotics, which I was fitted and still waiting for them to come in. 

Last month, in what I honestly felt was a last ditch effort, I see another well respected Sports Chiropractor.  So far, I'm seeing light at the end of the tunnel.  She has noticed so many issues with my feet, knees, hips, back, etc., that all of the other professionals never noticed, combined.  I've gotten dry needling and adjustments and making progress to the point I might start light walk/jogging in a couple more week. 

She believes, as well as I do, that my hip is the symptom of so many skeletal issues from not running or training properly over the years.  Now that I'm 41, my body and father time has caught up with me.  It's going to take time, but she believes things can be fixed. 

However, last Sunday she recommended some light plyometrics to see if her therapy was making progress.  The pounding and force of running is what causes pain.  I do the exercises and feel great, zero pain or discomfort...but, from last Monday to tonight, the pain and discomfort is right back to where it was last year.  I feel I've made no recovery and I'm once again at square one. 

I'm disheartened and honestly losing any hope I'll ever run again.  Depression is starting to set in.  IS THERE ANYTHING LEFT TO TRY? 

Answer by Troy Smurawa, M.D.
Member AMSSM

Of all the major joints, the hip joint remains the most difficult to evaluate for most orthopedic and sports medicine clinicians. Early identification of hip pathology and treatment can reduce the development of symptomatic hip osteoarthritis. Risks factors for the development of osteoarthritis include femoroacetabular impingement, labral tearing, developmental dysplasia and slipped capital femoral epiphysis. Recent advances in hip arthroscopy offers treatment in the early stages to prevent or slow down the progression of osteoarthritis. Extra-articular causes of hip pain are also common causes of hip pain in the active athlete. Common extra-articular causes include greater trochanteric bursitis, snapping hip syndrome, hip flexor and adductor tendinitis, proximal iliotibial band syndrome, piriformis syndrome, femoral stress fractures and strains of the hip external rotators. Both traumatic and overuse injuries contribute to the causes of hip pain. Therefore, in evaluating the etiology of hip pain in athletes it is imperative to distinguish between intra-articular and extra-articular as the cause of the hip pain.

The first step to the clinical diagnosis of hip pain in athletes is a thorough history. The cause of the hip pain is narrowed down by obtaining pertinent information in regards to the setting and description of the pain. Questions to ascertain include whether it is traumatic or non-traumatic, the duration and severity of the pain, exacerbating and alleviating factors and prior injuries and treatments.

The second step is to delineate between intra-articular and extra-articular causes of hip pain. Determining the exact location of the pain often aids in distinguishing whether it involves the joint or not. Intra-articular pain presents as groin pain, pain that may radiate to the knee, or the “C” sign of cupping the hand around the hip. A snapping hip or pain in the lateral or posterior hip often reflects muscle or soft tissues etiologies whereas pain that radiates below the knee, that causes weakness or exacerbated by coughing or sneezing signifies a spinal etiology. Lower abdominal and adductor pain is related to athletic pubalgia and osteitis pubis. Past medical, surgical and developmental history can also give clues as to the etiology of the hip pain. The location and source of the pain is further isolated by determining the athletic activities, movements and sports that recreate the pain. Certain activities stress different anatomical structures and are more likely associated with different etiologies. Clicking and locking are associated with intra-articular mechanical symptoms, pain associated with running often affects the hip musculature and repetitive low energy trauma may produce injuries to the labrum.

The third step is performing a detailed directed physical exam. The examination starts with the athlete in the upright standing position. The examiner assesses gait and pelvic obliquity to both functional and anatomical abnormalities such as leg length differences, scoliosis and degree of hip motion. Hip strength and stability are quickly assessed by observing a single leg stance squat test called the Trendelburg test. This identifies weak hip abductor muscles. Hip range of motion tested in both the seated and supine position assesses internal and external rotation, abduction and adduction, and flexion and extension. Decreased passive range of motion typically signifies an intra-articular problem. Provocative hip test are performed to stress specific anatomical structures intra-articular and extra-articular such as the hip labrum, the sacroiliac joint, the pubic symphysis, the iliotibial band, muscle and tendon contractures, and neurologic structures. An intra-articular injection of the anesthetic Lidocaine is often utilized to determine if the source of the pain is from the hip joint. If the pain goes away or significantly diminishes this would indicate an intra-articular cause of the pain.

The fourth step to the clinical diagnosis of causes of hip pain in athletes is the use of radiologic imaging. Plain radiographs are essential to look at the bony structures of the hip and pelvis. They help to identify evidence of hip dysplasia, bony femoroacetabular impingement, stress fractures, osteoarthritis and bony tumors as the cause of hip pain. Magnetic Resonance Imaging (MRI) is helpful to assesses muscles, tendons, ligaments and cartilage abnormalities. The MRI coupled with an arthrogram is used to identify an injury to hip joint labrum. Ultrasound is also used to image muscles and tendons for degrees of tears, swelling and degeneration.

Once a diagnosis is established a treatment plan is formulated to allow healing of the damaged tissue as well as address any functional, structural or biomechanical causes of the hip pain. Conservative treatment includes rest, anti-inflammatory medication, modalities such as ultrasound and electrical stimulation, manual therapy, a therapeutic injection and physical therapy. The focus of physical therapy is to address weakness, tightness, lack of mobility and stability as well as correcting any functional or biomechanical deficits. Therapeutic injections may include cortisone, platelet rich plasma (PRP) and dry needling. Surgical treatment is an option for repairing damaged structures or if conservative treatment has failed. The recent advances in hip arthroscopy provide surgeons with a variety of surgical procedures that are minimally invasive, have a shorter recovery time and improved return to activity outcomes.

Greater Trochanteric Pain Syndrome refers to a group of signs and symptoms that are related to pain in the trochanteric region of the lateral hip. This syndrome may occur as the result of one traumatic episode or as the result of multiple recurrent microtraumas. Greater trochanteric bursitis has traditionally been used as to describe pain located over the greater trochanter but recently it is recognized that this syndrome is more complex and may be related to other pathological changes to tissues in the peritrochanteric space. Pain localized around the greater trochanter is a condition commonly seen in the orthopedic and sports medicine office. Rasmussen and Fano(1) have developed a set of diagnostic criteria that require at least two of the following criteria to be present: lateral hip pain, tenderness about the greater trochanter, and one of the following: pain at the extremes of rotation, abduction, or adduction; pain on strong contraction of hip abductors; or pain radiating down the lateral aspect of the thigh (pseudoradiculopathy). Imaging studies are performed to rule out evidence of hip dysplasia, bony impingement, osteoarthritis, tumors or other bony deformities. Further imaging with an MRI is used to evaluate for muscle tears and strains in the hip abductor region.

Treatment options range from conservative treatment with rest and anti-inflammatory nonsteroidal medication to physical therapy and multiple local injections. Most cases result in minimal or no improvement and surgical treatment becomes an option for failed conservative treatment. Surgery ranges from iliotibial band release or lengthening with bursectomy (removal of the bursa) to femoral bone resection osteotomies. These techniques are perform either open or by endoscopic.

It is also important to identify any associated injuries to the abductor muscles in the peritrochanteric area. The gluteus medius and minimus muscles function as the main hip external rotators and hip stabilizers. Chronic repetitive microtrauma (overuse) leads to microscopic tears of the muscle and tendon leading to tendinosis (degeneration) of the tissue. This condition eventually leads to larger tears and possibly ruptures of the gluteus medius and minimus. These structures are often referred to as the rotator cuff of the hip. Leg length discrepancy, pelvic obliquity, high valgus knee position may all lead to alterations in the biomechanics affecting the iliotibial band causing tension and friction of the gluteus muscles. Athletes will often present with buttock, lateral hip or groin pain. The etiology is almost always related to microtrauma and overuse. The athlete reports a grinding sensation and pain with activities especially climbing stairs. Pain is palpated directly over the gluteus medius insertion or directly over the greater trochanter. Diagnosis is by clinical exam and confirmed by MRI or ultrasonography. An MRI identifies discreet tears, tendinosis, swelling and degeneration of the muscle and tendons. Nonoperative treatment of gluteus tendon tears may be successful if diagnosed and treated early. Treatment involves rest, physical therapy, NSAIDS and unloading the affected hip until symptoms resolve. Athletes who do not respond to conservative treatment or present with more advanced tears often require surgical treatment. Surgical repair is performed either by an open procedure or endoscopic approach. Studies have demonstrated that athletes are able to return to normal activities when treated with postoperative rehabilitation although it requires 6-12 months.

References:

Sports Related Injuries of the Hip. Clinics in Sports Medicine. 2011; 30(2).

Rasmussen KJ, Fano N. Trochanteric bursitis. Treatment by corticosteroid injection. Scand J Rheumatol 1985; 14:417-20.

Troy M. Smurawa, MD

Director, Sports Medicine Medical Education

Clinical Associate Professor of Pediatrics, Northeast Ohio Medical University

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date: August 31, 2015