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Hip Pain in the Athlete

Athletes presenting with hip pain are like snowflakes – no two are exactly the same.  This is because there are many structures in and around the hip joint that can result in pain, and by the time patients present to their physician for evaluation, there are often multiple contributors to the problem.  However, in most cases, a straightforward approach to the patient allows a proper diagnosis to be obtained – the first step toward solving the problem.  This article will briefly review the most common causes of hip pain in active adolescents and adults.  Due to the constraints of time and space, simple strains of muscles around the hip will not be discussed.

Adolescents presenting with discomfort around the hip most commonly are having pain that originates from outside the joint itself.  Since growth centers (apophyses) on the pelvic bone remain open through late adolescence, these athletes often develop problems related to rapid acceleration or sprinting.  The forceful contraction of the powerful muscles of the thigh can result in the widening of the cartilage growth centers they attach to or even pull them off completely.  The most common areas of involvement include muscles such as the hamstring, hip flexors, quadriceps and abdominal wall muscles.  These injuries, which can cause significant pain and short-term disability, rarely ever require surgery, and almost always heal without long-term pain or weakness.

Hip pain sometimes results from the recurrent snapping of certain tendons over bony protrusions around the joint.  “Snapping Hip Syndrome” originates from two primary locations.  This most commonly results from the snapping of a long tendon on the outer thigh – the IT band – over the bony prominence (greater trochanter) that can be felt at the lateral thigh.  A less-common cause, but still seen frequently in our clinic is a snapping of the hip flexor tendon over a bony prominence in the front of the pelvis.  This causes an irritation and swelling of the tissue (bursa) that sits between the two structures.  Both of these problems can be remedied with attention to strengthening and directed flexibility exercises.  Occasionally a directed injection is necessary to eliminate the pain.

Gluteus medius syndrome is a tendonitis that often develops in runners who lack good core stability.  The gluteus medius muscle helps stabilize the thigh bone and pelvis during running.  If an athlete is prone to fatigue of this muscle, microtearing can develop within the tendon, leading to tendon thickening, scarring, and chronic lateral hip pain.  Often directed exercises will take care of this problem.

Patients with hip, thigh and abdominal weakness (core instability) can develop a tearing of the abdominal muscle attachments near the pubic bone, resulting in what is commonly referred to as a “sports hernia.”  Patients with sports hernia typically present with pain in the front of the thigh, worse with kicking or side-to-side movements.  A careful exam and high suspicion for the problem will often lead to this diagnosis.

Stress fractures can occur around the hip in several different places.  Pubic bone stress fractures typically cause pain in the groin or at the midline while stress fractures of the ischium or tailbone (sacrum) cause posterior thigh or buttock pain.  The hip bone itself can develop stress fractures  These injuries can develop at the neck of the hip or further down the shaft of the bone.  These stress fractures – particularly ones involving the neck of the femur – are potentially dangerous, since they are at risk to fracture completely, resulting in significant disability.  Patients with femoral stress fractures often have anterior hip or thigh pain.  Although weight bearing is difficult, more commonly the patient walks into the office, noting pain only with exercise.  X-rays in these patients are often normal and further imaging is required to confirm the diagnosis.  In most cases, these injuries respond well without surgery, sometimes with a period of crutch protection and rest.

Labral tears are injuries to the cartilage rim which surrounds the socket portion of the hip joint.  These can occur traumatically following a forceful blow into the hip, such as during a motor vehicle accident where there is a head-on impact while the brake pedal is being forcefully applied, or during an awkward landing.  Labral tears can also occur because of a mismatch in fit between the ball and socket joint.  This latter problem is termed “femoroacetabular impingement,” or FAI.  People can impinge (entrap) their hip because the head of the hip joint is somewhat oblong rather than circular, or because the free edge of the socket joint is more extensive than it should be, leading to entrapment against the thigh bone when the leg is used in sport.  Patients with FAI will often develop tearing in their labrum over time because of this entrapment, but also develop pain related to abnormal bone-on-bone contact pressures in the hip.  This increased joint stress can lead to early breakdown of the joint to the point that the hip can become arthritic.  Pain in FAI is usually felt around the front or side of the involved joint.  The treatment of labral tears depends largely upon the underlying cause and can range from physical therapy to surgical correction of any anatomic problem or isolated arthroscopic repair of the labral tear.

Osteoarthritis of the hip is another potential cause of hip pain.  Patients with hip arthritis can present at varying ages, with younger patients presenting because of pre-existing problems that increase risk.  Symptoms of arthritis can range from pain in the groin, lateral thigh or buttock, as well as radiating pain into the knee.  X-rays are usually all that is required for diagnosis.  Patients with hip osteoarthritis often respond well to medication or injection, along with exercises to increase leg and core strength.

Avascular necrosis is a condition that occurs when the blood supply to the hip joint is disrupted, resulting in pain and loss of integrity of the bone.  Eventually, this can lead to collapse of the ball of the hip joint, requiring total hip replacement.  When detected early, there are procedures that can be performed to try to restore blood flow to the bone and save the hip.  Patients with AVN often present with pain and stiffness in the thigh or knee and often have pain at night.

Rarely, benign tumors can present around the hip.  These rare causes of pain present with symptoms that depend upon the area of involvement.  X-rays often, but not always are adequate for diagnosis.

As can be seen, hip pain in athletes can arise from a multitude of sources, and often takes some sorting out in the office setting in order to arrive at a proper diagnosis.  If you or someone you know is experiencing hip pain that is limiting your ability to perform, call us for an appointment.  We’re happy to help.

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