Hip pain for runners
An estimated one in five adults runs for exercise or recreation. Runners report average yearly injury rates from 24% to 68%, of which 2% to 11% involve the hip or pelvis. Although a variety of musculoskeletal conditions produce hip pain, other organ systems can refer pain to the hip and pelvic region. A careful history is important in the successful management of any running injury. Injured runners should be questioned about the nature of their symptoms, injury onset, duration, and precipitating and alleviating factors, and prior injury. Other features to be noted include how long the individual has been running, competitive level, cross-training activities, distance and frequency per week, training schedule, warm-up and stretching routine, and any recent change in training program. When evaluating a training program, physicians should include careful questioning about changes in volume, intensity, shoe wear, and terrain. Most injuries in runners are due to overuse rather than an acute injury. This holds true for both soft-tissue and bony injuries. Repetitive stress with insufficient time for tissue recovery is the major causative factor. The history may point to an underlying biomechanical cause that should be addressed in treatment. It's important to elicit details of prior treatments and evaluate shoe-wear patterns. In the female athlete, additional history should include questions about the presence of amenorrhea or oligomenorrhea, disordered eating, weight loss, and previous stress fracture. Often these issues need to be revisited on subsequent visits after a relationship has been established with the patient. The term "female athlete triad" is used to describe a syndrome of concurrent amenorrhea, disordered eating, and osteoporosis seen in some women. Early identification and treatment of this syndrome can prevent long-term sequelae, particularly in relation to bone health. Physical examination is performed with the patient barefoot and wearing shorts. Inspection should include static alignment and gait analysis, which is often performed with and without shoes. A complete musculoskeletal evaluation of the affected anatomy should be completed. The presence of scoliosis, femoral anteversion, abnormal Q angle, genu valgum or varum, tibial torsion, leg-length inequality, muscle atrophy, or muscle contractures should be noted. Active and passive range of motion, strength, and flexibility should be assessed and compared with the asymptomatic side. Imaging is used to confirm the clinical diagnosis.
Finally, shoes should be inspected for overall wear, uneven wear patterns, and type of last. Gait analysis and guidelines for shoes will assist athletes in the selection of appropriate shoes for their foot type. 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 control. Most shoes lose at least 30% of their shock absorption capacity after 500 miles of running. Continued use of shoes beyond this point results in increased force transmission to the lower extremities. Most experts recommend replacing shoes after 300 to 500 miles of use. Tendon insertion injuries occur in skeletally immature patients primarily between the ages of 14 and 25 (4). This most commonly is a chronic traction injury at the tendon insertion site that includes a gradual onset of pain with no clear history of injury. Examination reveals tenderness to palpation at the musculotendinous insertion into bone. An avulsion fracture at the site of tendon insertion is usually acute, and the displaced fragment may be bony or cartilaginous. The mechanism of injury is an excessive force from a violent muscle contraction that occurs across an open apophysis. These are located at the top of the iliac crest, superior to the acetabulum, greater trochanter, lesser trochanter, ischial tuberosity, and the symphysis pubis. The usual symptom of an apophyseal avulsion fracture is a sudden onset of pain, swelling, and weakness. Generally, there is no history of direct trauma. X-rays will confirm the diagnosis, and comparison views of the contralateral side may be helpful. Treatment of apophyseal injuries depends on the phase of recovery.
Ice should be used beginning with phase 1 (rest), and a non steroidal anti-inflammatory drug (NSAID) may be started after 48 hours. Most of these injuries are managed conservatively, and indications for surgical fixation are exceedingly rare. Premature return to sport before completing phase 4 (stretching, strengthening, and proprioception) may result in re-injury. Avulsion of the anterior superior iliac spine (ASIS) occurs with a sudden contraction of the sartorius when the hip is extended with the knee flexed. On examination, localized tenderness and/or swelling is noted and flexion and abduction of the thigh provokes symptoms. On radiograph, displacement of the ASIS is noted. Marked displacement is rare. Avulsion of the anterior inferior iliac spine (AIIS) occurs after contraction of the rectus femoris with vigorous kicking. Examination reveals local tenderness and swelling in the region of the AIIS and exacerbation with active flexion. Radiographs demonstrate displacement of the AIIS. The ischial apophysis is the site of the hamstring and adductor magnus origin, and it is the last apophysis to unite (at approximately age 25). The mechanism of injury is a vigorous hamstring contraction with the hip flexed and the knee extended. In runners, this injury occurs most often in hurdlers. The athlete complains of pain at the ischial tuberosity and difficulty sitting. There may be a pronounced limp. On examination, hip flexion with the knee extended will reproduce symptoms; thus, the presentation and examination are similar to a hamstring strain in an adult. Radiographs demonstrate a displaced fragment of the ischial tuberosity; displacement of the avulsed fragment greater than 2 cm may require surgical fixation. Complications are more frequent than apophyseal injuries of the ASIS and AIIS. In addition, time away from sports is often longer than that of other apophyseal avulsion injuries. Acute avulsion of the iliac crest apophysis in a runner occurs with the sudden contraction of the abdominal musculature that is opposed by simultaneous contraction of the gluteus medius and tensor fascia latae. This may result from excessive arm swing and trunk rotation while running and may occur with a sudden change in direction. On examination, symptoms are reproduced with resisted abduction of the ipsilateral side and palpation of the iliac crest. Oblique radiographs will reveal an avulsion of the iliac crest. Avulsion of the lesser trochanter apophysis may occur with sudden contraction of the iliopsoas. The athlete experiences a sudden onset of anteromedial hip pain while running. On examination, passive internal and external rotation and active hip flexion reproduce symptoms. Gait is antalgic. Radiographs demonstrate an avulsion of the lesser trochanter. Trochanteric bursitis commonly produces an aching pain over the lateral hip that is exacerbated by activity such as prolonged standing, lying on the same side, stair climbing, or running. In runners, it is commonly the result of overuse rather than direct trauma. Although the classic symptom is lateral hip pain, it may radiate to the groin, or, in approximately one third of patients, pain will radiate into the lateral thigh. On examination, pain is reproduced with external rotation and abduction and by resisted abduction. Patrick's (FABER) test is positive, and the hip abductors are often weak. Iliotibial band (ITB) tightness may be present. Palpation elicits tenderness along the posterior greater trochanter. Gluteus medius tendinopathy can mimic trochanteric bursitis, but it is distinguished by tenderness on palpation superior to the greater trochanter. Some authors have suggested that a more accurate term is "greater trochanter pain syndrome" to reflect the role that tendinopathy of the gluteus medius and minimus are thought to play. Magnetic resonance imaging (MRI) has documented tendinosis and tears of the gluteus medius. Although the diagnosis is clinical, radiographs should be obtained to evaluate for the presence of osteoarthritis or other osseous abnormalities. Pyriformis or obturator internus insertional enthesopathy (tendonitis)can occur with pain being felt just behind the greater trochanter. This is a common cause of pain in runners. Other muscles such as the gemelli also insert in this area and can cause pain due to tendonitis. Treatment of both trochanteric bursitis and gluteus medius tendinopathy consists of rest, ice, ITB stretching, strengthening of the hip girdle and trunk musculature (especially gluteus medius), and NSAIDs. Recalcitrant cases usually respond to a local corticosteroid injection. Mechanical precipitants such as leg-length discrepancy, ITB tightness, and pes planus should be addressed. Runners should avoid banked tracks or roads with excessive camber when resuming their running program. Ischial bursitis may occur as a complication of an injury of the hamstring insertion into the ischial tuberosity. Symptoms include pain while sitting and localized tenderness on examination. Initial treatment consists of rest, ice, NSAIDs, hamstring stretching and strengthening, and protection. Often a doughnut cushion will alleviate the patient's symptoms while he or she is sitting. Aspiration of the bursa and injection of a corticosteroid should be considered for recalcitrant cases. Rarely, surgical excision of the bursa for persistent pain and disability is indicated. Iliopsoas or iliopectineal bursitis involves anterior hip or groin pain. The cause of pain is thought to be irritation of the iliopsoas tendon over the iliopectineal eminence. Placing the hip in flexion and external rotation relieves 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. Most strains occur acutely, usually as a result of a sudden, violent, eccentric muscle contraction rather than concentric contraction. Strains are more common in competitive runners and in events such as sprinting or hurdles. The athlete often reports feeling a sudden pulling or tearing. Continued activity will exacerbate symptoms. The amount of ecchymosis and swelling is variable. Injury encompasses a spectrum from minimal hemorrhage and structural damage to a complete tear. Functional loss and a palpable mass are the hallmarks of a partial or complete tear. Hamstring injury is a common cause of hip or posterior thigh pain. The biceps femoris is the most frequently injured of the hamstring muscles. Risk factors for hamstring strains include insufficient pre running stretching, leg-length discrepancy, muscle imbalances, poor 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. A palpable defect may be present. Adductor strains are a source of groin pain in runners. Other potentially serious conditions may cause groin pain in the athlete and should be ruled out. An adolescent with groin pain often has an underlying pathologic process such as avascular necrosis, developmental dysplasia, Legg-Calvé-Perthes disease, or slipped capital femoral epiphysis. These entities should be included in the differential diagnosis along with, for older athletes, apophysitis, 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 to palpation and a palpable defect may be seen. 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. Initial management of all muscle strains previously noted consists of rest, ice, compression, protected weight bearing, and gentle range-of-motion exercises. Use of NSAIDs is controversial in the first 48 hours because of antiplatelet effects, but it is recommended after 48 hours. Rehabilitation goals include restoration of full range of motion, strength, and sport-specific skills prior to return to running. Return to competition is usually after 4 to 6 weeks, depending on the severity of the initial injury. 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. The underlying pathophysiology of a stress fracture is a failure to allow adaptation to mechanical loads placed on bone. This imbalance of bone resorption and bone formation represents a spectrum of injury that results in a fracture through the cortex if adequate time for repair is not allowed. Fatigue fractures occur when abnormal loads are applied to normal bone; in contrast, insufficiency fractures occur when normal stress is applied to abnormal bone. In most cases, a careful history will elicit a training error that has resulted in a stress fracture. It is critical, however, that consideration be given to an underlying metabolic or endocrine disorder in any athlete with a stress fracture. 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 not related to athletes' gender per se, but to factors such as amenorrhea, bone density, and diet. Female endurance athletes in particular are at increased risk of amenorrhea and stress fractures. All female athletes who have stress fractures should be screened for components of the female athlete triad. Recurrent stress fractures increase the index of suspicion for amenorrhea, an underlying eating disorder, and osteoporosis. The clinician should realize that athletes are often reluctant to discuss disordered eating behaviors. Other risk factors include anatomic factors such as excessive pronation, increased age, low calcium intake, training errors, and wearing worn-out running shoes. The classic symptom of a stress fracture is progressive activity-related pain that is relieved with rest. If the athlete continues activity, the pain will increase until it eventually becomes constant. A focal area of increased tenderness, erythema, swelling, and warmth may be noted on physical examination. A region of periosteal thickening may be palpable. The single-leg hop test reproduces symptoms. Percussion of the bone distal to the site of interest may produce pain. The initial diagnostic approach when a stress fracture is suspected is plain x-rays. Unfortunately, most are normal, and only about 50% of follow-up films demonstrate findings consistent with a fracture. The classic finding on x-ray is a localized periosteal reaction. In many instances, the patient may be presumptively treated for a stress fracture and repeat radiographs taken in 2 to 3 weeks. In the competitive athlete, or when a high-risk stress fracture is suspected, further imaging is indicated. The next diagnostic test in the evaluation of a stress fracture is a radionucleotide bone scan that will be positive within 48 to 72 hours after the onset of symptoms. The combination of radiograph and bone scan allows a correct diagnosis in 90% of cases. MRI has an evolving role in the management of stress fractures. The sensitivity of MRI is similar to bone scan, but its specificity is greater. Follow-up radiographs are indicated when symptoms persist despite adequate compliance with treatment or to document healing of a high-risk fracture. Specific treatment is predicated on the fracture location and radiographic appearance; however, some general principles apply. Attention to adequate nutrition in terms of energy balance and vitamin requirements is critical. In particular, calcium balance should be addressed. Male athletes under 24 years old and all female athletes usually require 1,500 mg of calcium per day, and men older than 24 require 1,000 mg. In addition, 400 IU per day of vitamin D is recommended for enhanced calcium absorption. 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 that allow the tissues to adapt to mechanical stress. An athlete who has ceased running for more than 4 weeks usually requires at least 8 weeks of rehabilitation to resume rigorous training at pre injury levels. Endurance runners may develop stress fractures of the pelvis. Repetitive hip adductor contraction is thought to produce stress fractures of the pubic ramus. Symptoms include pain in the inguinal, perineal, or adductor region that is relieved with rest and exacerbated by activity. Hip range of motion is often normal, but the athlete is unable to stand unsupported on the affected extremity. A pronounced limp is present, and tenderness to palpation occurs over the rami. Initial radiographs are usually negative, but a bone scan will be diagnostic. Treatment consists of protected weight bearing for 4 to 6 weeks followed by a gradual return to activity. Return to unrestricted activity usually takes 3 to 5 months. Follow-up radiographs may show an abundant callus formation at the fracture site that should not be confused with malignancy. Femoral neck stress fractures often occur in distance runners. The athlete may have groin, hip, thigh, or knee pain and nocturnal groin pain is common. This stress fracture is usually activity related, and a recent change in mileage or activity often precedes symptoms. The athlete may have an antalgic gait. Pain occurs at the end range of hip motion, especially internal rotation and flexion. Stress fractures of the femoral neck are considered to be "high risk" because of the potential morbidity associated with them. Radiographs are often negative for 2 to 4 weeks. Bone scan or MRI should always be obtained in an athlete who has a suggestive history and negative plain films. MRI has the advantage of greater localization and grading of injury severity and in differentiating stress fracture from other bone and soft-tissue conditions such as avascular necrosis. Early recognition is important because of the propensity for complications if the condition goes untreated. Prognosis is based on location, with fractures traditionally classified as either a compression or a distraction or tension fracture. Compression fractures occur at the inferomedial aspect or compression side of the femoral neck. If initial radiographs do not show evidence of displacement, management consists of bed rest until the athlete is pain-free, non-weight-bearing locomotion with crutches, and frequent repeat radiographs. When radiographs demonstrate evidence of complete healing, progressive weight bearing and activity are permitted. Recurrence of pain warrants rest for 2 to 3 days, then resumption of activity at the last level tolerated. Fracture progression is an indication for immediate surgical stabilization. Distraction or tension fractures occur in the superolateral aspect of the femoral neck. This is a region under biomechanical tension. Propagation of the fracture line occurs perpendicular to the femoral neck. Tension-type fractures have a high risk of displacement and should always be referred to an orthopedic surgeon for management. They tend to occur in older patients. Standard management consists of internal fixation and non-weight bearing for 6 weeks, followed by 6 weeks of partial weight bearing. A displaced femoral neck stress fracture is an orthopedic emergency requiring immediate surgical reduction and fixation. Complications of fracture displacement include avascular necrosis, deformity, delayed union, and nonunion. Sacral stress fractures have rarely been reported in distance runners. Athletes with these fractures usually report vague buttock or low-back pain without a history of trauma. Examination reveals tenderness to palpation along the sacrum and sacroiliac joints. If plain radiographs are negative, a bone scan is usually diagnostic. Treatment consists of rest with gradual resumption of activity. The treating physician should maintain suspicion for this injury among running athletes, especially young women, who report sacral and buttock pain that does not adequately respond to treatment. Osteoarthritis may be a source of hip and groin pain in runners. Patients describe activity-related pain in the groin and, frequently, nocturnal pain. On physical examination, gait may be antalgic, and an abductor limp may be present. Range of motion is limited by pain. Typically, internal rotation is most restricted. Radiographs demonstrate loss of joint space, osteophytes, and other degenerative changes. Initial treatment consists of NSAIDs, weight loss if appropriate, activity modification, and strengthening of the pelvic girdle musculature. Attention to flexibility and strength of the entire kinetic chain should be addressed. Acetaminophen has been demonstrated to be useful in the long-term management of osteoarthritis and, in general, has fewer side effects than NSAIDs. While running has not been shown to cause osteoarthritis, it may accelerate disease progression once degenerative changes are present in the hip. Athletes with osteoarthritis often resist a complete cessation of running and, if so, a limited amount may be continued with alternative, nonimpact aerobic activities, such as swimming and biking, as good substitutes. Many runners will require guidance to safely resume running and prevent re-injury after injuries are fully rehabilitated. Attention to risk factors such as nutritional status, proper footwear, and type of training program may prevent recurrent injury. Alternating easy or rest days with harder training days is another effective way to prevent injury. Increasing training volume 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. A review of the athlete's training program for errors can be helpful. Cross-training activities, such as swimming, biking, and using a cross-country skiing machine can be used to maintain aerobic conditioning. When less than 4 weeks of running have been missed, adjustment of training volume should be based on the previously tolerated volume. For example, an individual who was running 20 miles per week and missed 2 weeks because of injury should resume running at 10 miles the first week. 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 at the last-tolerated level. Persistent symptoms despite compliance with the protocol should prompt reevaluation. Here’s a brief run down on the most common types of hip problems seen in runners. Muscle Strains Contusions (Hip Pointer) Stress Fractures Osteitis Pubis Sports Hernias Snapping Hip Syndrome Traumatic Hip Subluxation & Dislocation Hip Arthritis Low Back Strain
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