Your Hips Have a Reason to Hurt

Hip pain can be a debilitating disease that can lead to significant impact on a patients’ physical and mental health. Long-standing hip pain can cause anxiety and depression in those that linger without a diagnosis. There are various causes of hip pain, many of which have overlapping symptoms and a similar presentation. Though many of these symptoms are “typical” of their respective disease state, some causes of hip pain can have an “atypical” presentation.

 

Femoroacetabular Impingement (FAI)

Since the hip joint is centered in the groin it is very common to have anterior (front) groin pain with FAI. Many times this will occur while sitting for long periods or with deep flexion. Additionally, patients may experience pain on the side of the hip (lateral hip pain) and may use their hand in a C-shape to indicate its location. Perhaps less common but still associated with FAI, some select patients will have pain in the buttock area (posterior hip pain). This can occur with certain activities or while sitting.  And there are the unlucky patients that will have pain in multiple locations. Labral tears associated with FAI will often have a gradual onset of pain without a definite history of trauma such as a fall or twisting injury. Patients typically experience pain with cutting and twisting maneuvers. If symptomatic FAI does not resolve with conservative measures such as physical therapy, NSAIDs and injections then this may be an indication for arthroscopic labral repair.

 

After Hip Arthroscopy

The longest term data on arthroscopic labral repairs shows that at 10 years with the appropriate patient selection we can predict excellent results in most patients. However, there are a few unlucky patients that do not have even good results following arthroscopic hip surgery. There is a multitude of reasons for this. The most common of which is residual FAI that was not adequately addressed at the initial surgery. This usually has a period of doing well that is followed by the return of symptoms by 1-2 years.  This can also be similar in patients that have microinstability. These generally require a revision arthroscopy to address the residual FAI and/or microinstability. In patients that have frank (bad) instability, the general presentation is that they are worse than before surgery. Often times these patients have a capsular deficiency that could require an arthroscopic capsular repair or even a capsular reconstruction. 

 

Developmental Dysplasia of the Hip (DDH)

DDH is a pelvic deformity where the acetabulum (socket) is too shallow or vertical to keep the femoral head (ball) stable. This instability is very subtle and only rarely presents with dislocation of the ball out of the socket. While thought of as an infant and children’s disease DDH can present in adolescents and adults. When this happens, typically the deformity is not as severe. Often times the symptoms of DDH will be similar to that of FAI with pain occurring in the groin, side of the hip and buttock areas. If symptoms do not improve with conservative measures such as physical therapy, NSAIDs and injections then this may be an indication for a periacetabular osteotomy (PAO). As many DDH patients also have features of FAI including labral tears this is usually performed concomitantly with an arthroscopic labral repair.

 

Microinstability of the Hip

Newly recognized and described (but also heavily debated), microinstability appears to play a major role in hip pain, especially in the female population. Though the hip is thought to be a very stable ball and socket joint, there is slight micro-motion that allows the ball to slide or shift within the socket. While some of this micro-motion is normal, when it becomes too much it can cause the hip to be painful and sore. This increased motion occurs for various reasons: Too shallow of a socket (DDH), soft tissue laxity such as Ehlers-Danlos or generalized hypermobility, muscle imbalance, increased femoral anteversion or a combination of multiple factors. With instability, the etiology must be found to determine the treatment. If there is inadequate bony coverage of the hip a periacetabular osteotomy (PAO) may need to be performed. If there is soft tissue laxity and arthroscopic labral repair with capsular plication could be indicated.

 

Hamstring Tear or Tendinosis

The hamstring is a large muscle group on the back of the thigh that when injured can also cause pain around the hip. Mostly this will be in the buttock area near the ischium (sit bone). This can be due to repetitive injury and degeneration at its attachment site (tendinosis) or an acute rupture or tear. This occurs usually with a hyperextension injury of the hip.  If the tear is acute it is generally followed by large amounts of swelling and bruising in the back of the thigh. While some of these will heal on their own and not cause long term symptoms, other times the tears can be accompanied by painful debilitating spasms. For symptomatic hamstring tendinosis and tears an endoscopic or endoscopic assisted hamstring repair could be indicated if conservative measures such as physical therapy, NSAIDs and injections have not adequately relieved pain.

 

Gluteus Medius/Minimus (Abductor) Tears

The gluteus medius and minimus muscles start at the iliac crest of the pelvis and form tendons that attach to the greater trochanter of the femur (bony knob on the side of your hip). While some may be acute, generally injuries of these muscles develop over time and predominantly affect females. Typical symptoms are pain over the trochanter (bursitis) and when tears are large enough, they will present with a limp or (Trendelenburg gait). This is due to the inability of the muscle to balance or keep the pelvis level while walking, which makes bursitis that much worse. Most patients that present with tears are middle-aged females that have had multiple trochanteric hip injections without significant relief of their symptoms. In that instance, an MRI would be appropriate to determine if there is in fact a tear. With MRI evidence of a tear and marked abduction weakness, an endoscopic repair may be indicated if conservative measures such as physical therapy, NSAIDs and injections have failed to relieve symptoms and improve function. PRP recently has been shown to be effective at both 3 months and 2 years at relieving symptoms and improving the function of the hip and may be an important adjunct in the treatment of abductor tears.

Our experienced hip specialists are well versed in both operative and non-operative care of the hip including arthroscopic labral repair as well as in-office ultrasound-guided hip injections.

Don’t wait until the pain is unbearable or severely limits your activity. Give us a call at 816-841-3805 to schedule an evaluation, or contact us online today. 

Author
Dr. Dustin Woyski Orthopedic Surgeon and Hip Specialist

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