Hip pain for runners

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

Injuries to the hip and pelvis are common in runners.

Most of these injuries are due to overuse. Tendon insertion injuries are prevalent. Stress fractures and soft-tissue injuries occur in all age-groups, often because of excessive mechanical stress without enough recovery.

An estimated one in five adults run for exercise or recreation. Runners report average yearly injury rates from 24% to 68%, of which 2% to 11% involve the hip or pelvis.

A careful history is important in the successful management of any running injury.

Details to be noted include how long the individual has been running, cross-training activities, distance and frequency per week, warm-up and stretching routine, and any recent change in training program.

Questions should be asked about changes in volume, intensity, shoes, and terrain.

As mentioned earlier, repetitive stress with insufficient time for tissue recovery is the major causative factor for many injuries. The history may point to an underlying biomechanical cause that should be addressed in treatment. It's important to find out details regarding previous treatment.

In the female athlete, history should include questions about the presence of amenorrhea or oligomenorrhea, disordered eating, weight loss, and previous stress fracture. The term "female athlete triad" is used to describe a syndrome of concurrent amenorrhea, disordered eating, and osteoporosis seen in many women.

Gait analysis can help in the selection of the right shoes. In general, a high-arched or rigid foot should have a flexible or cushioned shoe, and a flat-arched or flexible foot should have a motion-control shoe that will provide rearfoot stability. Most shoes lose at least 30% of their shock absorption capacity after 500 miles of running. Beyond this number of miles, excessive forces are transmitted to the lower extremities. Most experts recommend replacing shoes after 300 to 500 miles of use.

An avulsion fracture at the site of tendon insertion is due to excessive force from muscle contraction at a tendon insertion point.

Ice should be used immediately and a non steroidal anti-inflammatory drug (NSAID) may be started as well. Most of these injuries will respond to conservative management.

Avulsion of the anterior superior iliac spine (ASIS) occurs with an abrupt contraction of the sartorius muscle with the hip in extension and knee flexed. Localized tenderness is noted and flexion and abduction of the thigh mimic symptoms.

Avulsion of the anterior inferior iliac spine (AIIS) occurs after contraction of the rectus femoris with kicking motions. Examination reveals local tenderness and swelling in at the and worsening with active flexion.

The ischial apophysis is the site of the hamstring and adductor magnus origin. A hamstring contraction with the hip flexed and the knee extended is the usual mechanism of injury. There is pain at the ischial tuberosity and difficulty sitting. Hip flexion with knee extension will reproduce symptoms similar to that seen with any hamstring strain.

Trochanteric bursitis produces a pain over the lateral hip that is worsened by activity like prolonged standing, lying on the same side, stair climbing, or running. In runners, it is commonly the result of overuse. Iliotibial band (ITB) tightness may be present. There is tenderness along the posterior greater trochanter.

Gluteus medius tendinopathy can mimic trochanteric bursitis, but there is tenderness superior to the greater trochanter. Magnetic resonance imaging (MRI) shows tendinosis and tears of the gluteus medius.

Pyriformis or obturator internus tendonitiscan occur with pain being felt just behind the greater trochanter. This is a common cause of pain in runners.

Treatment of all these forms of tendinopathy consists of rest, ice, ITB stretching, strengthening of the hip girdle and trunk musculature (especially gluteus medius), and NSAIDs. Stubborn cases usually respond to a local corticosteroid injection. However, a more physiologic treatment is ultrasound-guided needle tenotomy with platelet-rich plasma. This is often curative. Factors such as leg-length discrepancy, ITB tightness, and pes planus should be addressed. Runners should avoid banked tracks or roads when resuming their running program.

Ischial bursitis is due to an injury of the hamstring insertion into the ischial tuberosity. Symptoms include pain while sitting and localized tenderness on examination. Treatment consists of rest, ice, NSAIDs, hamstring stretching and strengthening, and protection. Often a doughnut cushion will alleviate the patient's symptoms when sitting. Aspiration of the bursa and injection of a corticosteroid may help.

Iliopsoas or iliopectineal bursitis causes anterior hip or groin pain. The cause of pain is due to irritation of the iliopsoas tendon over the iliopectineal eminence. With the hip in flexion and external rotation there is relief of symptoms. Hip extension (stretching of the iliopsoas) exacerbates the symptoms. As with other types of bursitis, treatment consists of rest, ice, NSAIDs, and stretching of the iliopsoas.

Muscle strains include partial and complete tears at the musculotendinous junctions.

Hamstring injury is a common cause of hip or posterior thigh pain. The biceps femoris is the most frequently injured hamstring muscle. Risk factors for hamstring strains include poor pre-running stretching, leg-length difference, muscle imbalance, lack of flexibility, prior hamstring injury, and poor technique. On examination, pain is reproduced by flexion of the hip with the knee extended or by resisted flexion of the knee.

Adductor strains are a source of groin pain in runners.Other issues that can cause similar symptoms include femoral neck stress fracture, iliopectineal bursitis, osteitis pubis, osteoarthritis, pelvic stress fracture, hernia, and "sports hernia." On examination, pain is reproduced with passive abduction and active adduction. Localized tenderness is present.

These soft tissue injuries should be evaluated by either MRI or diagnostic ultrasound. Depending on the severity and chronicity, a patient may be considered for injection using ultrasound needle guidance. Because there is less emphasis on glucocorticoids which basically put a "band-aid" n the problem, and more emphasis on the healing potential of platelet rich plasma (PRP), using ultrasound needle guidance for localized PRP injection may be the treatment modality of choice.

Quadriceps strains usually occur at the musculotendinous junction. The rectus femoris is most frequently involved. On examination, pain is reproduced with passive flexion and active extension of the knee. Palpation will localize the injury.

PRP injection using ultrasound needle guidance is also helpful here.

Initial management of all muscle strains previously noted consists of rest, ice, compression, protected weight bearing, and gentle range-of-motion exercises. Return to running prior to full restoration of flexibility, strength, and endurance predisposes the athlete to recurrent injury and impaired performance.

Stress fractures can occur in the hip, pelvis, or thigh.

Underlying conditions that predispose bone to an insufficiency fracture include amenorrhea, hyperparathyroidism, hypothyroidism, osteoporosis, Paget's disease, rheumatoid arthritis, and steroid use or abuse.

Among athletes, females have been reported to be at 1.5 to 3.5 times greater risk of stress fractures than are males. The difference is related to factors such as amenorrhea, bone density, and diet. Female endurance athletes in particular are at increased risk of amenorrhea and stress fractures. s.

The classic symptom of a stress fracture is activity-related pain that is relieved with rest.

MRI is usually diagnostic.

Relative rest with non weight bearing or partial weight bearing should be initiated. In most cases, cross-training activities may be instituted early in the treatment process. Activity resumption requires recovery periods.

Endurance runners may develop stress fractures of the pelvis. Symptoms include pain in the inguinal, perineal, or adductor region that is relieved with rest and worsened by activity.

Treatment consists of protected weight bearing for 4 to 6 weeks followed by a gradual return to activity. Return to full activity usually takes 3 to 5 months.

Femoral neck stress fractures often occur in runners. The athlete may have groin, hip, thigh, or knee pain and nighttime groin pain.

MRI should always be obtained in an athlete who has a positive history and negative plain x-rays.

Sacral stress fractures have been reported in distance runners. Symptoms are vague buttock or low-back pain without a history of trauma. Examination reveals tenderness along the sacrum and sacroiliac joints. Treatment consists of rest with gradual resumption of activity.

Osteoarthritis may be a cause of hip and groin pain in runners. Patients describe activity-related pain in the groin and, frequently, nighttime pain. Typically, internal rotation is restricted. X-rays show loss of joint space, osteophytes, and other degenerative changes.

Snapping hip syndrome is a word 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, around the hip socket can cause a snapping sensation.

Treatment consists of anti-inflammatory drugs, weight loss, activity modification, and strengthening of the pelvic muscles. While running has not been shown to cause osteoarthritis, it may accelerate disease progression once degenerative changes are present in the hip. Cross-training with non-impact aerobic activities, such as swimming and biking is recommended if an athlete chooses to continue to run.

Alternating easy or rest days with harder training days is another effective way to prevent injury. Increasing training by no more than 10% per week allows adaptation to mechanical stress as speed and intensity are gradually reintroduced.

Flexibility and strengthening should also be included in the athlete's rehabilitation protocol. Cross-training activities, such as swimming, biking, and using a cross-country skiing machine can be used to maintain aerobic conditioning. Yoga is an excellent form of stretching.

A rest day incorporated after every third day of running decreases the risk of recurrent injury. If symptoms recur, the athlete should rest 1 or 2 days, then resume activity. Persistent symptoms should prompt reevaluation.

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