Member Case Study: Lingering Hip Pain

author : AMSSM

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Near the end of one of my long runs, I noticed my left hip aching. There was a slight pop with each step. The hip was sore for 2 days after the run.

Question from KRCSWO
I started cycling Fall of '05 with indoor spin classes. I am new to triathlon training this year. I was running 2x per week while tri training. Varying terrain between road and trail, including small hills. I followed the 10% rule closely ramping time and distance slowly. I improved to a 1hr 15min LSD run time. Then near the end of one of my long runs, I noticed my left hip aching. There was a slight pop with each step. The hip was sore for 2 days after the run. Since then, any running longer than 35-45 minutes and the pain returns.

It is bad enough to stop me from running, slowing to a walk after the 45 minutes. Pain stays for 1-2 days, then is no longer noticeable. The pain seems to vary between muscle pain and joint pain. While running, it seems to be joint pain, with the popping of the joint. After running it seems to be muscle pain, with pain getting worse while trying to lift the leg straight out in front. (Hip flexor?)

Cycling does not seem to bother it. Swimming doesn't bother it. Walking doesn't seem to bother it. Long 3hr + challenging hikes make it noticeable, but do not hurt much.

I talked with my doctor about it, his comment was that if it hurt to run, don't run. After reducing my running to almost nothing for a couple of months, the pain is still there when I do run.

What is likely causing the problem?

Answer by Amy Powell, MD:

If the pain is on the outer part of your hip, it may be due to a common condition known as “snapping hip syndrome.” There are several causes of a snapping hip, which are best diagnosed based on the location and type of your pain. The most common cause of snapping hip syndrome occurs when the iliotibial (IT) band (a thick fibrous band running down the outer thigh) “snaps” over the greater trochanter, a bony prominence of the thigh bone (femur).

When you are still, the IT band is behind the greater trochanter, but with running, the IT band moves forward. As it moves back and forth during the running stride, the athlete may feel and/or hear a “snap.” This may or may not be painful, but may lead to irritation of the IT band or inflammation of the bursal sac adjacent to the greater trochanter, which is called “trochanteric bursitis.”

Athletes with this type of snapping hip syndrome usually complain of pain at the outside of the hip and leg with activity. A less common cause of snapping hip syndrome occurs in the front of the hip, where the iliopsoas tendon (an important hip flexor) crosses over a bony prominence in the pelvis called the iliopectineal eminence. This is known as “internal snapping hip syndrome” and results in pain and snapping deep in the groin. This is typically an issue in activities requiring repetitive hip flexion and external rotation, especially uphill running. The iliopsoas bursa may also become irritated in this condition, leading to bursitis.

Other possible causes for your symptoms include early hip osteoarthritis, a tear in the labrum (cartilage) of the hip, or a “loose body,” which is usually the result of trauma. Typically, these problems would all cause pain deep in the groin region, and are sometimes associated with a sense of the joint “sticking” or “locking.”

If you are examined by a sports medicine doctor (see www.amssm.org for a list of physicians in your area), he/she will examine your lower back, abdomen, pelvis, and hip region. If rotational movements of the hip are not painful, it is less likely that x-rays are needed to evaluate for true hip joint problems.

If your doctor determines that your pain is being caused by snapping hip syndrome, he/she will look for biomechanical factors that may be leading to the “snapping,” such as inflexibility (particularly of hip flexors, IT band, hamstrings, hip adductors), relative areas of muscle weakness (including the core), and foot biomechanics (such as overpronation). Your doctor may enlist the help of a sports medicine physical therapist to evaluate your running mechanics, help with improving strength and flexibility, and guide a return-to-sport program.

In the meantime, if swimming and cycling are pain free, keep it up, as cross training can be helpful in allowing you to maintain your level of conditioning while you recover from your injury. Good luck!

Amy Powell, MD

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date: September 3, 2006