THE SPORTS DOCTOR

By Dr. Michael Gross

Hip pain is a common complaint that can be caused by a wide variety of problems. Sometimes, the key feature to determining the cause of hip pain is understanding the anatomy and knowing where the hip joint is.

The hip joint itself is located deep in the groin. Out to the side, in the area that most people commonly refer to as their “hip,” is the edge of the hipbone, or femur, known as the greater trochanter. Towards the back is the sacroiliac joint; this is usually considered part of the lower back, or pelvis. Sometimes understanding where the pain comes from can help make the diagnosis.

Your hips are strong and stable when healthy, but injury and certain conditions – like osteoarthritis and osteoporosis, both common in older – may affect the health of the hips. Arthritis is among the most frequent causes of hip pain in athletes and non-athletes alike, and because arthritis effects the joint itself, arthritic pain is usually first felt in the groin. People with arthritis often have stiffness and tenderness in their hips; this can make walking very uncomfortable. If the arthritis is severe, it can also make sitting, standing and lying on that side uncomfortable. High impact activities on an already arthritic hip that is asymptomatic may exacerbate the pain and cause a sudden onset of symptoms. For athletes, playing sports, running, falling, heavy impact and overuse can lead to hip strains, hip pointers, hip bursitis and something called femoroacetabular impingement.

Bursas are small sacs of lubricating fluid located at various joints in the body. The sacs are particularly important in the elbow, shoulder, knee, heel and hip joints. They act as shock absorbers and cushions between bones and tendons. If the sacs become irritated or inflamed, the condition is called bursitis. Trochanteric bursitis is an extremely common problem that causes inflammation in the bursa over the outside of the hip. This pain takes place over the outside of the hip. Trochanteric bursitis can be very tender and can make it difficult to sleep on that side. Hip bursitis is the most frequently reported cause of hip pain. It is more likely to affect middle-aged and older adults rather than younger athletes and exercisers, and women more often than men.

Snapping hip syndrome is a term used to describe three distinct hip problems. The first is when the IT band snaps over the outside of the thigh. The second occurs when the deep hip flexor snaps over the front of the hip joint. Finally, tears of the cartilage, or labrum, inside the hip socket can cause a snapping sensation. Snapping hip syndrome is often caused by tight muscles and can be treated with rest from aggravating activities, appropriate stretching exercises, and occasionally anti-inflammatory medications. Surgery is rarely necessary.

Labrum tears, or torn cartilage, in the hip are a cause of hip pain that we are learning more about every day as hip arthroscopy becomes more common. The acetabular labrum is a small band of tissue located along the rim of the socket of the hip joint. The labrum looks and feels like a rubber band. It acts as a cushion as the ball of the hip comes into contact with the cup in extremes of motion.

The labrum can be torn by a twisting or slipping injury, or over time by repetitively compressing the labrum between the femoral head and cup. An athlete with a labral tear will usually complain of pain to the anterior groin. The pain is often worsened with certain motions, especially hip flexion. Sometimes a quick sharp pain or catching sensation can be felt with certain motions. As the condition worsens, pain can be felt with walking and sitting for long periods of time. If a labral tear is suspected, physicians will usually order a special type of an MRI of the hip, called an MRI arthrogram. Small labral tears can be treated with physical therapy, but larger tears usually require surgical treatment.

is a condition in which abnormal bone growth causes bone spurs on both the femur and the acetabulum The constant rubbing damages the articular cartilage on the round head of the femur and the labrum, the cartilage rim around the hip socket.

The hip is a ball and socket joint. For reasons not completely understood, some people develop excessive bone tissue at the top of the femur and around the edge of the hip socket. These people are not born with FAI. It appears to develop early in life as the person grows. The movement that aggravates FAI is a forceful rotation of the core, including the hips. The longer that repetitive rotational movement occurs over a period of years, the more irritated the area becomes, the more pain can be felt because of bone to bone contact,

and the more likely osteoarthritis will develop. When enough cartilage has been worn away from the top of the femur, the athlete will feel the pain.

FAI comes in two forms – cam and pincer. Most patients have a combination of the two. Cam impingement results from excess bone located at the neck (top) of the femur. Pincer impingement is caused by excessive bone tissue on the acetabulum/socket of the pelvis. If a physical therapy program is unsuccessful, removal of the spurs and repair of the damage can be successfully performed arthroscopically as an outpatient with excellent results.

A hip pointer is one sports injury in which you, the athlete, can probably make a diagnosis as quickly and accurately as a physician. You’ll know it has happened when you get hit or fall on your side, and the first thing that absorbs the blow is the outer part of what most people would call the hip bone, which is a misnomer. Actually, a hip pointer is a deep bruise, or contusion, on the top portion of the pelvis that can be felt on either side of the waistline. The distinguishing characteristic is hip pain, plain and simple.

It’s not a career-ender, but it is a painful injury that can keep you out of action for days or weeks if you don’t take care of it and if you rush back into training or competition before it has healed. It is difficult to manage because the strong muscles that attach put constant stress on the area.

Muscle strains are common cause of pain and spasm around the hip and pelvis areas. The most common strains are in the groin and hamstring. Hip flexor strains can range from mild to severe, or in medical terms, from first to third degree. A first degree hip flexor strain means one of the hip flexor muscles has been stretched or slightly torn. A second-degree strain refers to a partial tear of the muscle or tendon, and in a third-degree sprain, the muscle or tendon is completely severed– a rare event. When a tendon is pulled off the bone at the place where it is attached, it is called an avulsion fracture. Depending on the severity of the injury, recovery time ranges from a few days to months.

Fractures can occur in the hip area. Some are a result of stress fractures and some are acute fractures. Stress fractures of the

hip are most common in athletes who participate in impact sports, such as runners, and occur over time from over training. Acute hip fractures are most common in elderly patients with osteoporosis. Treatment of broken hips usually requires surgery.

Many back and spine problems can cause symptoms around the buttocks and hip. The most common problems that refer pain to the hip region are herniated discs, sciatica and sacroiliac dysfunction. A sports hernia is caused by a tear in the muscles of the lower abdomen where they attach to the pelvis and can cause pain that initially feels like hip pain. Sports hernias are more common in male than female athletes. Athletes with a sports hernia usually complain of pain in the lower abdomen or groin. The pain is worsened with coughing, sneezing or quick motions in sports such as sprinting or sidestepping.

X-rays and occasionally an MRI may be used to rule out other conditions. Initial treatment consists of resting from aggravating activities, ice, anti-inflammatory medications and physical therapy. Surgery is occasionally required when symptoms have failed to improve with extensive non-surgical treatment.

Any hip pain that persists more than a few days, keeps getting worse, starts to keep you awake or wakes you up, makes you limp or unable to walk is serious and should be seen by a doctor. A sports medicine the physician with a comprehensive joint and cartilage preservation program is probably your best bet. This way you be able to take advantage of the most up-to-date non-surgical and surgical methods to keep you in the game.

Dr. Michael Gross is the founder of Active Orthopedics & Sports Medicine, now a Summit Health company. He is the clinical director of Orthopedic Surgery for Summit Health, the chief of Sports Medicine at Hackensack University Medical Center and the chairman of Orthopedics at New Bridge Medical Center. He is also an assistant professor at Hackensack Meridian School of Medicine.