“One goal of early intervention is hip preservation. Treating some of these intra-articular problems can help slow and possibly eliminate the need for a total hip replacement in the future.”
Dr. Thomas Akre, orthopedics and sports medicine, Allied Bone and Joint
The holiday season is here and the Cubs have won the World Series. All good news, right? But what about that nagging hip pain? While nobody wants to slow down (knowing all that good food that is on the way,) if there is hip pain, it may be time to consider the source. First, we evaluate the cause. There are several reasons for hip pain and location of the pain is often helpful to establish the diagnosis.
The hip is a ball-and-socket joint with many surrounding structures. The femoral head fits tightly into the acetabulum or socket. The articular cartilage covers the femoral head and most of the acetabulum. The central inferior point is the ligamentum teres which brings some blood flow to the head and adds some support to the joint. An injury to this ligament can lead to a sense of hip instability and subluxation.
Surrounding the acetabulum is the labrum. This is somewhat like a rubber seal around a windowsill or a rubber gasket around a joint, providing a suction seal to the hip joint. Minor repetitive trauma such as extremes of motion, forced hip flexion or major trauma such as a sports injury or a car accident can injure the structures. With the recent advances in hip arthroscopy, we are better able to understand and treat pathology inside the joint. Early arthritic changes can also be evaluated and treated.
One goal of early intervention is hip preservation. Treating some of these intra-articular problems can help slow and possibly eliminate the need for a total hip replacement in the future.
Surrounding the bones of the hip joint is a very strong structure called the hip capsule. The inner lining of the hip capsule is the synovial membrane. The synovium provides lubrication and nourishment to the joint cartilage. Injuries to the hip joint can cause inflammation of the synovium which leads to swelling and pain. Standard treatments such as rest, ice, compression and elevation known as RICE is a common approach for most orthopedic injuries. With modification of activities and physical therapy as well as anti-inflammatory medicines, such as ibuprofen, many injuries will resolve with a little time and these conservative treatments. If six weeks of conservative measures are not showing significant improvement, it may be necessary to further investigate the cause of the pain.
Outside of the capsule are muscles, tendons and neurovascular structures surrounding the hip joint. Muscles are critical in maintaining dynamic support to the joint and provide the power we need to do not only sporting activities but daily activities of life. Keeping a life in motion is critical for general wellbeing. When sprains and strains occur around the hip joint, utilizing the conservative measures above will oftentimes resolve the issue.
Bursitis and lateral hip pain
Occasionally tendons become inflamed or a bursa that provides a protective and lubrication barrier between tendons and bone can become inflamed. Problems of tendonitis or bursitis when unresolved with conservative measures may require more aggressive treatment. Certain types of injections with cortisone can alleviate the problems.
– A bursitis problem on the lateral, or outside of the hip is called greater trochanteric bursitis. This pain is more associated with standing, walking and direct pressure on the side, such as sleeping on your side. Trochanteric bursitis often gets better with cortisone injections. If the cortisone injections do not resolve the pain an underlying partial tear of the gluteus medius tendon may be the reason. This muscle attaches near the top of the greater trochanter. Oftentimes, people have difficulty keeping their pelvis level while walking. This is known as a Trendelenburg gait and usually implies a full thickness tear.
– A tear in the gluteus medius tendon can usually be identified with an MRI, and arthroscopic or open treatment may be necessary for repair. This is somewhat analogous to a rotator cuff tear in the shoulder. The person with hip pain associated with persistent greater trochanteric bursitis that is unrelieved with injections and physical therapy should seek out an orthopedic surgeon familiar with this type of injury.
Other common sources of lateral hip pain include:
- referred pain from the lumbar spine, such as spondylosis or spine arthritis. Typically extension and side bending to the effected side will recreate the pain. ν IT band, or iliotibial band, tendonitis. Proper running shoes and stretching with a foam roller are useful treatment options.
- Snapping IT band syndrome which may require surgical release of a portion of the fascial band.
Anterior hip pain
Anterior hip (groin) pain can be from femoral acetabulum impingement syndrome known as FAI. This is often associated with labral tears and is created from impingement; either from a spurring or prominence on the acetabulum right under the labrum known as a pincer lesion or the impinging of a spur or prominence on the femoral neck, known as a CAM lesion, or a combination of both. Different congenital hip morphology can predispose a person to this problem as well. People with FAI usually have difficulty with prolonged sitting, flexion of the hip joint when rotated and they may have popping and snapping sensations as well.
After a thorough history and physical exam, other diagnostic modality may include an MRI to rule out conditions such as a vascular necrosis. An MRI with arthrogram may improve the assessment of a labral tear. Sometimes an intra-articular injection of numbing medicine such as lidocaine can be very beneficial in evaluating whether the pain is coming from the hip joint or another source. Cortisone can also be added to the numbing medicine in an effort to decrease inflammation secondary to synovitis.
Once confirmation is made that intra-articular pathology exists, surgical intervention may be the best option. Arthroscopic treatment to remove the spurs and repair of the labrum can be very successful as 90 to 95 percent of patients report improvement. This procedure is done as an outpatient surgery. Patients usually use crutches and a brace for approximately four weeks to protect the repair and decrease postoperative inflammation. The labral repair should usually be healed enough by three months to allow a person to start returning to strengthening and agility exercises. No contact sports or aggressive activities are permitted for six months.
– Snapping iliopsoas tendon is a rare but additional reason for anterior hip pain. This usually occurs in thin women and is noted as a palpable (and sometimes painful) snapping occurrence in the front of the hip with certain hip movements. Usually releasing a portion of this tendon arthroscopically where it crosses the front of the acetabulum can resolve the problem. ν Other causes for anterior hip pain are: hip flexor or adductor strains, nerve entrapment, upper lumbar disk disease or problems from abdominal or pelvic origin.
When surgery is needed
Orthopedic surgery for hip pain has improved significantly in the last 15 years. Options have become more refined and techniques have improved significantly. Living with hip pain until the need for a hip replacement is no longer necessary. Although hip replacement may be the only option in some cases depending on the extent of arthritic changes, arthroscopic minimally invasive outpatient surgery is here to stay.
Maintaining a healthy active lifestyle with good diet and exercise should be the mainstay for all people, but when hip pain is limiting the ability to live life in motion it may be time to look into the options.