By: Maggie Gebhardt, PT, DPT, OCS, FAAOMPT
The hip joint can be a source of pain for many people and the reason why can often be confusing. The most common thing we think of when it comes to hip pain is arthritis. However, there are many different causes of hip pain not related to arthritis at all. These injuries can happen to the everyday person who likes to participate in recreational sports: the weekend runner, the high school ballet dancer, the neighborhood tennis league participant, etc.
The hip joint connects the lower leg to the pelvis and back. It is supported by many muscles, ligaments, tendons, nerves and inert structures that allows it to have the range of motion, stability, and flexibility that we require of it. It is a hip that is often painful and injured as a result of overuse, biomechanical faults, or traumatic activities. The pain is not arthritic in nature and therefore the treatment option is not a replacement. However, it can still be very uncomfortable and limit your ability to participate in your recreational activities.
Patients who have these non-arthritic hip complaints will often have the same story of a prolonged diagnosis, differing diagnoses, numerous diagnostic tests, and often failed attempts at conservative management. The good news is that with a thorough evaluation including a variety of Physical Therapy assessment tools it can be accurately diagnosed.
Some of the non-arthritic hip conditions are labral tears, impingement, bursitis, and IT band syndrome just to name a few. There are many different variables that can affect the nature of the injury and these must all be taken into consideration when determining the best course of treatment.
Below you will find a list of non arthritic hip conditions and the best treatments performed by Physical Therapists.
What is a labrum? It is a cartilaginous ring that runs around the perimeter of your hip socket and allows the ball to sit deeper in the joint. This allows for more stability in the joint.
The labrum is most commonly torn on the inside of the hip near the groin and that is why one of the primary complaints someone will have is groin pain. Some other commonly expressed symptoms are popping, clicking, stiffness and instability. The labrum can be torn or irritated due to trauma or just abnormal mechanics causing rubbing of the head of the femur on the rim of the joint. While some tears require surgery, most labral tears have a good prognosis with Physical Therapy including manual therapy and exercise.
The biggest way a Physical Therapist can impact the diagnosis of a labral tear is by changing the mechanics of the hip and leg to normalize function and prevent any further aggravation. If correct mechanics are restored and maintained the tear should not be a constant source of pain.
Unfortunately, without surgery the tear will not heal on its own and will always be present. So, there can be times where if a sudden movement or turn happens, the patient can experience an exacerbation of their original pain. However, with the correct maintenance plan, one should be able to manage an acute exacerbation on their own. Even with a labral tear, it is possible to return to all activities, as long as there is a commitment to the program established by the Physical Therapist to maintain proper hip mechanics.
If considering surgery, rehabilitation prior to the surgery has been shown to have beneficial outcomes. The intent of pre-surgical rehabilitation is to restore the hip mechanics, strength, and stability as much as possible so that after surgery the groundwork has already been laid. It has been shown that deciding to delay surgery to attempt conservative management first does not negatively affect the surgical outcomes. Meeting with a Physical Therapist before surgery is usually the preferred option.
Labral tears can be hard to diagnose, and it can be frustrating for the patient to get an accurate diagnosis. It is important for patients to find a physician and Physical Therapist who have experience in this area and can help guide them down this path.
Hip Impingement
The diagnosis of hip impingement is often associated with diffuse and hard-to-diagnose hip pain. Impingement in and of itself is not a horrible diagnosis, but many have come to fear it because if not treated appropriately it can lead to the more involved diagnosis of a labral tear.
The clinical terminology for impingement is Femoral Acetabular Impingement (FAI) and is caused by the femoral head (the ball) rubbing against the labrum (cartilage ring around the socket) due to poor mechanics of the hip joint or possibly a structural limitation. Commonly FAI occurs when there are repetitive motions (running, twisting, etc.,) causing overuse at that junction of the labrum and femur.
Poor mechanics often involve a shift in the dynamic balance between the smaller stabilizing muscles and larger force-producing muscles of the hip in which there becomes more of a bias towards larger muscles putting increased strain on the hip. The goal of therapy should be to shift the bias back to the smaller stabilizing muscles to allow the hip to move more freely and decrease the pinching.
Unfortunately, if this shift is unsuccessful then the labrum will continue to get worn down and tear which will eventually cause one to have to consider surgery. However, with the participant being diligent in their program usually this condition can be conservatively managed and with some regular maintenance the patient can return to most of their prior activities with minimal dysfunction.
Hamstring injuries can fall into two types: 1. Some form of a muscle strain or tear and 2. Tendinopathies.
Muscle strains or tears can vary in degree of severity. The can range from a minor strain or “muscle pull” to one that is fully torn. If someone has a fully torn muscle, they will typically report an acute onset of pain, hearing a pop, and a deep, ugly bruise that shows up a couple of days later and can extend past the knee. After the acute inflammatory phase, these injuries tend to heal quickly especially with lots of R.I.C.E.
Tendinopathies are way more common and much less talked about. These groups of injuries are the ones that come on slowly and may not notice until it’s almost too late. They can be nagging, at first and it may seem that they will never get better. Any place you have a tendon (a tendon connects muscle to bone) is a location where you can develop a tendinopathy.
In the hip the origin of the hamstring muscles, the “SITS” bones, is where tendinopathies typically present. People who have a hamstring tendinopathy will often complain of pain when sitting and crossing their legs. These hamstring tendinopathies take a long time to heal because unfortunately they are very difficult to avoid using and really need their rest to heal. If you are upright, you’re most likely using them.
In the case of tendinopathies, there are a lot of viable conservative options that you can discuss with your physician. Typically, these options work best when coupled with Physical Therapy. Physical Therapy for this issue should not only address the specific tendon but should also address the biomechanical faults that initially caused the tendon overload. An experienced Physical Therapist will be able to look at the movement patterns of your lower body and determine the inefficiencies that could have led to this overuse condition.
Iliotibial Band (IT Band) Syndrome
The Iliotibial Band, IT for short, can be the cause of a lot of knee pain in runners. In particular pain on the outside of one’s knee. There is a lot of information out there on how to manage this type of pain with lots of gizmos and gadgets for one to purchase. However, what most people do not realize that this issue often stems from poor hip mechanics causing overuse if the IT Band.
When there is poor hip stability due to weak hip muscles, primarily the glutes, there is an increased reliance on the IT band to stabilize the knee. The pain one experiences is from the inflammation at the site where the IT Band attaches to the outside of the knee. Until the proper mechanics of the lower leg are restored it can feel like one is caught in a painful cycle of pain and irritation with any activity. Thru the use of many therapeutic techniques, the Physical Therapist can interrupt that painful cycle and get you back out on the road again!
Piriformis Syndrome
The diagnosis for Piriformis Syndrome is commonly overused and misdiagnosed. Many people assume that they have Piriformis syndrome if they have hip tightness and especially in the presence of any type of nerve symptoms. When in fact nerve symptoms and hip tightness can have a number of causes. In actuality it is very rare to come across a true case of Piriformis syndrome.
Piriformis Syndrome is when the piriformis muscle becomes so tight that it causes numbness, tingling and/or pain down into the respective leg. The piriformis muscle is oriented along the backside of your hip, sits amongst your gluteal muscles, and runs from your tailbone to the outside of your hip.
All of the symptoms mentioned above can occur with or without the piriformis ever being involved. That’s what makes this a hard syndrome to accurately diagnose. Numbness, tingling, and/or pain down into the leg can have numerous causes including, but not limited to: herniated disc, facet syndrome, foraminal stenosis, glute trigger points, and neural tension of the lower extremity nerves. Those with piriformis syndrome will also have the above symptoms, but clinically there are objective tests your therapist can take you through that definitively help to diagnose if the piriformis muscle is the culprit.
If you are one of those rare people who actually have an affected piriformis, usually the cause is poor leg mechanics. The poor mechanics can be due to weakness of the stabilizing hip musculature. Physical Therapy can help with proper strengthening, stretching, and other modalities for pain and to improve the neural integrity of the nerve that was being compromised.
Athletic Pubalgia
Athletic Pubalgia is more commonly known as a Sports Hernia. People with a Sports Hernia will initially complain of groin pain that spreads to the inner thigh as the condition progresses. If the genito-femoral nerve is involved, the patient can also present with numbness or other nerve-related symptoms in the thigh, the scrotum in males, and the pubis in females. Most often the pain is aggravated by extreme and repetitive twisting, turning, or extending the affected hip. The sports most commonly associated with this injury are football, hockey, tennis, and soccer.
This diagnosis can be a frustrating one for the patient and clinician alike due to the fact that it is a tear in the lower abdominal (most commonly the oblique muscle’s) fascial connection and therefore does not present with the bulge that is most commonly associated with a hernia. Oftentimes patients are told they have a groin strain and that it should heal with rest and anti-inflammatories. If indeed it is a strain the rest usually helps, but a true hernia will re-aggravate once activity is resumed. Once diagnosed, the condition can be treated conservatively with therapy or surgically. The surgery to repair this hernia is relatively new and it has been suggested to rename this condition as an “Inguinal Disruption.”
Physical Therapy should focus on normalizing the forces between the abdomen, hips, and pelvis to minimize stress to the affected area. Usually the conservative route is a longer recovery process and can be frustrating for the athlete with a small timeframe to return to sport. The ultimate goal is to correct the lumbo-pelvic and lower extremity mechanics to return the patient to their sport of choice without risk of further injury or re-aggravation.
Snapping Hip Syndrome
People will often come into our Boulder and Lafayette Physical Therapy clinics asking about non-painful snapping emanating from their hip. Although rare condition, Snapping Hip can create a sense of alarm, not because of the pain, but because of the loud snapping noise that is the hallmark characteristic of this condition.
The sound is created by one of two things:
- The IT Band snapping over the head of the femur.
- The Iliopsoas Tendon (part of the hip flexor complex) ineffectively stabilizing the joint, causing the joint to click as it moves through its range of motion.
Both of these scenarios are not cause for immediate concern, but reflect incorrect biomechanics occurring at the hip. A hypermobile body type will predispose one to the latter scenario. If there is more generalized core and gluteal weakness, then overuse of the IT Band is more likely to occur. In either scenario a Physical Therapist can help advise on some coordinated exercises and re-education of the hip muscles to ease the snapping.
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