My Hip Pain – Is It Bursitis?

Outer thigh and hip pain is common in athletes and non-athletes alike. Can’t run, can’t get comfortable at night, can’t do your regular yoga class without pain. What is causing it?

Women in their forties to sixties are especially prone to this type of pain. Specifically, those with leg length inequalities, scoliosis, low back pain, knee arthritis, and those who run. Though increasing your running time or distance is a common risk factor, interestingly, it is just as common in those who don’t or who rarely exercise.

Case in Point: Jenny (Runner)

Jenny is an avid runner, attaining 7-10km four days a week. Over the last two months, she had started to feel discomfort over her right thigh, which always got worse during her runs. It had been settling down with rest, but now it seems to be always present. Her hip is tender to the touch and she can’t sleep well at night when she lies on either side.

While all potential causes of hip pain need to be ruled out, she is likely experiencing her symptoms because of a compressed tendon in her hip called the gluteus medius.

We call this greater trochanteric pain syndrome, which is named for the area of discomfort on the outside of your hip. Your strong iliotibial (IT) band, which runs from the hip down to the knee, compresses the gluteus medius tendon when you bring your leg toward midline. When you have a faulty running or walking pattern, or weakness in your hip muscles, this compression can build up over time which will result in pain.

Solving Greater Trochanteric Pain Syndrome

Jenny decided to see her physiotherapist at PhysioActive. During the assessment it was determined that she did indeed have greater trochanteric pain syndrome. This was because of an underlying weakness of her hip abductors - the muscles that lift and rotate her leg outward and keep her pelvis level when upright. When she ran, her right hip dropped, which caused the leg to move inward with each step.

Jenny could pinpoint her painful area near the bony prominence on the outside of her hip. If she ran a lot, pain would get worse and travel down her leg to her knee.

Historically, the pain was thought to be was coming from a bursa, which when inflamed, is called a bursitis. Recent research shows however that a bursitis is not very common in those who report this type of pain on the outside of the hip. MRI has improved our knowledge of the cause of this pain – in a study of 24 patients with these symptoms, a whopping 92% had no evidence of inflammation of the bursa!  What was obvious in the majority of those studied was a deterioration of the gluteal tendons.

Armed with a goal of running without pain, Jenny followed her therapist’s advice and stopped running for three weeks. As the tendon in her hip was overloaded and compressed, the offending activity (running) had to be avoided to prevent further damage. Instead, she used the time to improve her swimming speed.

Treatment included soft tissue mobilisation, ultrasound and a specific hip strengthening and tendon loading program, followed closely by her physiotherapist. Occasionally, dry needling or shockwave would be added to the protocol to improve healing.

The exercise program was progressed over a period of 10 weeks, at which time Jenny had built back her running to 4-5km, twice a week. A few weeks later, she was able to attain her full training. The key to her success was the strengthening and balancing of the hip musculature. This allowed proper function of her pelvis and leg as she took each step, and significantly reduced the risk of recurrence.

Get Your Hip Properly Assessed

Simply treating the problem as a bursitis would have led Jenny to a poor outcome. Tendon injuries can be improved, with the proper identification and treatment. One advantage Jenny had was that she did not leave it for too long, hoping it would recover on its own. Tendons heal significantly better if caught early, which in turn minimises the time away from sport.

If you are experiencing symptoms similar to Jenny's, contact us today and get your hip properly assessed!

This post was written by Leah Kieffer.

Dealing with a Labrum Injury and Hip Pain

Hip pain and injury is a complex and fascinating field for us physiotherapists. As medical, anatomical and biomechanical science helps us to understand the entire body better, the hip and its problems are becoming clearer. What we do know is that it's always a multi-faceted issue to assess. Like all parts of the body, the hip is influenced by all around it.

The hip joint and its surrounding structures form a very strong unit that the body relies upon to transfer energy and force from the foundation of our spine to our lower limb extremities. It's a ball and socket joint, which allows movement in every direction. The joint and its surrounding muscle strength allows us to effectively transfer the power of our leg to the stability and control of our spine. This creates efficient movement in the ideal world. When this system is faulty, however, the consequence is an injury to the hip joint itself, or to any of the surrounding structures in the said chain of events.

The labrum is a ring of a cartilage type structure that sits around the socket part of the hip joint. It acts to:

Patients with a labral or cartilage injury will often describe:

Hip Scan

Injury to the labrum can be caused by:

  1. Trauma (including dislocation)
  2. Repetitive and sustained compression to a specific area of labrum
  3. Sports or daily activities
  4. Hip dysplasia (irregular shaping of the joint – genetic)
  5. Hypermobile joint (excessive flexibility)
  6. Impingement (compression caused by femur bone)

The key to understanding where to start with treating a labral injury is understanding the patient themselves - knowing the causes in their day-to-day lifestyle, and carrying out an in depth physical assessment. There are then many tests that help confirm a diagnosis of a labral tear for those with hip pain. Tests that  compress the joint surface and reproduce the patients symptoms are a very good way to pick up indications of labrum and or cartilage injury. 

When we have arrived at the diagnosis of a hip joint labral injury, there are then many factors that need to be corrected. Here, I will discuss these factors and how we go about fixing them:

  1. Joint restriction/stiffness

Having a tight hip joint will place greater stress on the cartilage and labrum. The best way to improve this is to use distraction techniques to gently open and stretch the joint itself. Massage to the surrounding muscles helps blood flow and can increase mobility.

 

  1. Muscle tightness

Key muscles that pose a problem for the hip joint are the hip flexors, the groin muscles (adductors), the deep hip rotators (piriformis) and the tensor fascia latae (TFL). Trigger point therapy, targeted stretches and self release, active release techniques, sports massage and dry needling are all successful when dealing with muscle tightness.

  1. Pelvis/lumbar spine

Any alteration to normal biomechanics in these areas will affect the hip joint. Both structures have many muscles that cross from one to the other, thus directly contributing to the way that the hip moves. A Pelvis rotation/twist is best fixed with manual mobilisation and manipulation, followed by core and muscle strengthening. Lumbar spine stiffness will also increase the demands on the hip, so stretches can really help.

  1. Weak core

A weak core means poor stability. Imagine running on sand as compared to concrete. When running on sand you have no stability - every muscle has to work harder, and your speed and power drop as there's no solid foundation from which to move from. Studies have shown that weak core muscles are a common factor in patients with hip pain, often related to previous injuries or misfiring muscles. Without these muscles helping to stabilise the area, the hip joint has to cope with considerably more stress. Specific exercises to target the transverse abdominus, the mulitifdus and the pelvic floor are often recommended by physios.

  1. Weak glutes

The glutes are a fascinating group of muscles, comprising of three muscles in the buttock area. They serve to create power when we walk and run. They create stability at the same time, and prevent a drop of the opposite hip when walking and running. Single leg squat and running assessments will pick up any issues with weak glutes. When combined with core strengthening, the hip joint and its labrum/cartilage are only going to be healthier from all of the the hard work.

 

  1. Flat feet and ankle stiffness

People with fallen arches are more likely to have hip pain. As the foot rolls in, the hip joint twists inwards slightly, compressing the front of the joint. Added up over the thousands of steps we take each day, an abrasive stress is only going to wear away at the labrum.

  1. Posture - Sitting and standing

Sitting compresses the front of the hip labrum and cartilage, and when combined with crossing your legs, a dangerous situation can arise. Fixing any issues ergonomically will help this - for example, if your chair is too low then the hip joint will be more flexed, and this will need to be corrected. Standing with all of your weight shifted to one side will jam your hip joint. This coincides with muscles weakness in your core and glutes, and is something that always needs fixing. Too often, this is a problem with young mums who only hold and carry their child on one hip.

One of the most crucial elements to treating people successfully is understanding the way that the patient moves. If we don’t solve the potentially harmful movement patterns that a patient has, then we won’t ever be truly successful with our treatment. Running assessments, golf swing analysis and other sports-specific tests are the best way to understand and correct movement pattern dysfunctions.

Now, it's also important to mention that the injury that does not always heal with conservative treatment. Some tears and degenerative injuries in the hip joint have a limited ability to heal due to limited blood supply. This may indicate the need to consult with an orthopaedic surgeon to understand potential surgery options. Avoiding this need for surgery is the aim of all physiotherapy treatment programs.

Hip joint pain is a debilitating and complex injury, and patients often leave it too long to have it fixed. For treatment to be more successful, it needs to be early on in the process. In the end, I implore patients to listen to their body more. You need to trust what your body is telling you before it's too late and the full injury process has set in.

Problems with Hip Pain?

Please get in touch with us today and book a physiotherapy session with Joel and the team.

Thanks for reading!

This post has been written by PhysioActive physiotherapist Joel Bates.

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