Hip pain is one of the main complaints presenting in my office. The cause of hip pain can vary from weight training, to traveling and prolonged sitting. While the main cause of hip pain can vary, patients are often unsure whether their hip pain is caused muscular problems or joint problems. There are a few simple ways to determine if the pain source is in the joint versus from muscular or other causes. To begin, lets first consider a short anatomy lesson followed by typical signs and symptoms followed by a potential diagnosis, treatment and rehab considerations. As always, nothing replaces an in person evaluation so if you think that you have some of these issues please make an appointment with an appropriate doctor.
The hip anatomy can be broken down into 4 different compartments: anterior, lateral, medial and posterior. The anterior anatomy consists of the hip flexor (iliopsoas muscle), quadriceps and sartorius muscles.
The lateral compartment consists of the TFL, IT-Band and parts of the oblique muscles (the glute medius and max can also be considered part of this group when it comes to functionality).
The medial compartment consists of the adductors, obterator externus and pectineus muscles.
The posterior compartment has the gluteal muscles (maximus, medius and minimus), superior an inferior gemellus, piriformis, quadratus femoris, obturator internus and externus, and the hamstrings.
As you can see, the posterior group has the largest amount of muscles. Because of increased sitting, it is no surprise that this area tends to be the most under developed. Completing glute exercises or posterior chain exercises are usually warranted when your back or hip is weak. The anterior portion flexes the hip and provides stability when landing during a walking, running or jumping phase. The lateral portion of the hip acts as an abductor and provides stability to the hip during the landing phase of the same motions mentioned above. When these lateral muscles are weak, the hip can flare out during walking meaning there is an instability in the joint. Think of a model walking down the runway swinging her hips side to side. The medial portion helps adduct the hip and extend the hip. This group provides minor stability when landing as well. Lastly, the posterior portion extends the hip. This portion of the hip allows us to propel forward when walking, jump, running, squatting and/or climbing stairs. When this area gets weak, patients tend to have a tight lateral hip as well as a tight and painful lower back on the same side.
The signs and symptoms of hip pain can be broken down to joint issues versus muscular imbalances and/or referred pain from nerve or back injuries. Here are some basic ways to determine which type of pain you have. Keep in mind, you are allowed to have symptoms of both such as a joint issue and a back injury referring to the hip.
- Joint pain
- Typically, joint pain will present with pain in the front of the hip near your groin. This pain is usually sharp and can loosen up after one gets moving. The pain can refer down the front of the leg without going past the knee. Patient will often say that it hurts in the morning when I first get up or it hurts after I have been sitting for a while. Patients will note that the pain goes away after they have moved around and used the hip, but it will get worse if they move around too much. At this point, an xray would help rule out osteoarthritis of the hip.
- Muscular pain/ bursa pain
- Most muscular pain originates in the back of the hip near the glutes. Keep in mind, this is a generalization, but I would be confident enough to say it is somewhere around 80% of the cases. Muscular pain tends to be ache and a little more spread out along the glute or side of the leg. Typical muscle injuries are called: gluteal tendonitis, trochanteric bursitis, IT-Band syndrome, a TFL strain and piriformis syndrome (which also mimics sciatic pain).
- Labral injuries
- The labrum is a piece of cartilage similar to the meniscus in that it is the same type of cartilage with very firm properties. The draw back to the firmness of the cartilage is that it does not have a very good blood supply. Therefore, an injury of this caliber has a high rate of surgical needs. That does not mean everyone requires surgery. Typical signs are very sharp pain in the front of the hip, locking of the hip or a sudden decrease in hip range of motion. This is an injury that needs an MRI to confirm this type of injury.
- Back injury
- A simple sprain or strain of the lumbar spine or SI joint can cause some referring pain to the posterior portion of the hip. Most people will notice the pain in their back referring to the hip while they are bending forward or arching backwards. If you get this type of pain when tying your shoes, chances are you have a back injury with a secondary muscular hip issue.
Once a diagnosis has been established by a qualified medical expert, treatment options are dependent on an individual’s availability, prognosis, age, weight and activity level. In my opinion, an integrated approach to hip pain is the best option. An integrated approach can range from NSAIDs with myofascial release and rehab to pre-hab, surgery then rehab. The type of treatment will be determined by medical experts; however, I will go over my approach based on the diagnosis.
If the symptoms are joint in nature, I would recommend seeing your primary for an opinion on NSAIDs while I would perform Active Release Technique along with Hawk Grips therapy, manual adjustments and at home prescribed rehab to improve mobility, flexibility and strength. Typically the main goal when it comes to joint hip pain is to create as much space as allowed in the joint area. The ART will allow improved space and better range of motion while the at home rehab will reinforce the improved mobility while strengthening the weak areas around the joint.
Pain that is muscular in nature is approached in a very similar way with a recommendation to see a medical doctor for potential medical intervention if it is a bursal issue. Muscular injuries tend to be more frustrating because the patient can still be active, but the pain seems to linger. One of the toughest things to do when someone has a muscular injury is to shut down from exercise. However, if a few weeks of care is not producing good results, often rest is need for the body to heal.
The dreaded labral injury needs to start with a surgical consult. You will not have to do this until an MRI confirms the tear. Prior to surgery, it is best to receive care in the form of rehab and muscle work in order to ensure the hip is as strong as possible prior to surgery. This will minimize recovery time and increase the chance or an earlier return to activity.
Finally, recommendations for back pain that causes pain referring into your hip. This type of injury is a chiropractors bread and butter. Performing soft tissue treatments to the surrounding area coupled with manual adjustments and at home rehab tends to have a good success rate. The at home rehab will also serve as exercise one would do as a preventative measure for hip and back pain.
In conclusion, hip injuries are very common. Hip injuries can occur for many reasons ranging from running to prolonged sitting. Individuals should realize that in absence of a definitive reason for injury, most hip injuries are a result of what we do every day. Do we lean to one side while talking, do we favor a cheek while sitting, do you run on a slanted road in the same direction, or do you need to get control of your weight to alleviate the stress on your hips. Movement is the key. Once you get your pain under control, working to improve the ability of your hips to move can minimize injury or re-occurrence of past injuries.
Here is a link to a few exercises that can help Hip pain: Hip Exercises
Sincerely,
Dr. Derek Gearhart
