Hip Impingement and Labral Tears
The hip has received much attention over last 12 years. Knowledge of hip pathology lagged far behind the shoulder and knee. This caused hip treatment to lag behind as well. These hip pathologies that have been the focus over recent years are impingement in the hip (known as femoroacetabular impingement or FAI), hip labrum tears (acetabular labral tears), and even more recently, occult instability.
FAI can be caused by several factors. Some people have more bone formation along the ball (head-neck junction of the femur or thigh bone). The atypical bone formation impacts the hip socket and can chip cartilage away and it can tear a cartilage ring (acetabular labrum) that surrounds the hip socket (acetabulum). Not everyone has this bony formation. Those who don’t have the atypical bone formation will more often tear the labrum but have less damage to the socket. FAI can contribute to hip arthritis at a younger age than one would expect.
The labrum is a cartilage ring that surrounds the hip socket (acetabulum). A labral tear may cause pain and clicking in the hip. Sports or activities that require significant range of motion in the hip or a great deal of rotation may produce a painful hip.
Occult instability of the hip is just beginning to be recognized as a contributor to hip pain. Subtle excessive motion of the hip can cause pain even if the labrum has already been surgically repaired.
The hip can also have long-term wear and tear of the hip that can lead to significant arthritic changes of the hip. This is quite common. The changes of arthritis can be so gradual that patients easily compensate for years and one day they notice the hip doesn’t move well, with our without pain. Some of these patients develop knee pain without hip pain.
Bursitis in various locations around the hip is quite common. The most common site is the outer hip (trochanteric bursitis). Bursitis can occur over one of the hip flexor muscles as well. Fortunately, bursitis usually responds well to a variety of conservative treatments.
Stress Fractures/Bone Stress Response
Some overtrained athletes have occult stress fractures, or may have bone stress responses, that are nearing the fracture stage. These areas of bone stress can be in the femur or the pelvis.
Lumbar Spine Related Hip Pain
There are lumbar spine pathologies that refer pain around the hip. These pathologies need to be considered in patients who do not have apparent hip pathology.
Hamstring/Adductor/Abdominal Muscle Injuries
There are other common injuries that are considered part of the hip. These injuries include hamstring strains/tears, adductor strains (“groin strains”), and tears of the abdominal muscles (“sports hernias”). These injuries are also areas of specialty at the Soft Tissue Center due to a very extensive history with elite track and field athletes who have hamstring strains, hip flexor strains, adductor strains, Achilles tendinitis and plantar fasciitis. Our experience with professional hockey players, hurdlers and powerlifters and their common adductor injuries (“groin strains”) and “sports hernias” or abdominal muscle injuries made the Soft Tissue Center an important diagnostic and case management facility.
Tests for the Hip
A special test, known as an MR arthrogram, is performed to best visualize the tear of the labrum in a FAI symptomatic patient. An angle of the bony formation is measured at this time as well. This information along with the history and clinical examination will determine which path of care is best.
It is important to understand that anatomy and function do not always correlate. A paper was published in 2012, which studied 45 asymptomatic hip patients who were given MR arthrograms. The results were 69% of these asymptomatic hip patients had labral tears as agreed upon by at least two radiologists. As you can see, the most important component of case management is the history and diagnosis. How a patient functions is more important that how his/her hip appears on imaging.
Hamstring and adductor muscle injuries require MRI studies if the injury is severe enough or the timing of the injury warrants the imaging. Suspected pelvic and femoral stress fractures or bone stress responses also may require an MRI to visualize bone edema from bone infrastructure breakdown. Chronic stress fractures may require additional tests to help determine their cause.
Lumbar injuries that are radiating pain to the hip or hamstring area may require a lumbar MRI, x-rays and possibly nerve studies.
Hip Injury Management
The doctors at the Soft Tissue Center at DISC are knowledgeable in the diagnosis and management of hip pathologies. The clinical data (history and examination) and imaging are compiled and when blended with the patient’s goals and needs will determine the treatment plan. Case management may be a combination of soft tissue mobilization to the key hip muscles and stretching of the posterior capsule (if indicated). Exercise or training modification recommendations may be required as well. Strengthening and stretching of muscles around the hip may help many hip pain patients. A referral to a specialist to consult about joint injections, which contain growth factors, may be in order. This approach can be combined with conservative care. A referral to an orthopedic surgeon with experience in hip arthroscopy may be indicated. These decisions are made on a case-by-case basis.
Athletes who have stress fractures, multiple stress fractures or a history of stress fractures may need to have several tests to determine the reason for the fractures. The effect of overtraining is not simply mechanical. The contributing factors that led to the stress fractures need to be identified so we can prevent future stress fractures that could lead the athlete to early retirement from his/her sport.
Those patients who have reached the point where a total hip replacement is needed to stop their hip and/or referred knee pain can benefit from a referral to an orthopedic surgeon who performs soft tissue-sparing surgical techniques. This approach to spare the soft tissues produces far less post-operative pain than the previous surgical methods. The soft tissue-sparing approach can produce significant outcomes as indicated by patients walking without crutches typically in a week or less, and walking one mile within five to six weeks (unless there are other complicating circumstances). Rehabilitation becomes much easier in patients who have had this method.
The hip is quite complex and has significant influence and impact on the knee as was published in 2012, and it can affect the lumbar spine by altering hip motion and the pelvic tilt. The often forgotten sacroiliac joint can be stressed as well from hip pathology. The doctors at the Soft Tissue Center can be your first step and help guide you through the process of diagnosis and the treatment plan whether the plan is rehabilitation with our group or if we need to refer you to another specialist for co-management of your hip pain.