Hip Pain

The Basics

  • Hip pain is pain that originates from the hip joint or the tendons, ligaments, and muscles that surround the joint. You may feel pain in the lateral hip bone, the groin, or the buttocks. Hip pain can radiate into the thigh and the back. Patients will frequently call pain at or above the belt line hip pain but that is usually back pain.

  • Patients who have a significant trauma such as a fall or an automobile accident need to be worked up for a hip fracture. Older patients can have hip fractures with minimal or no trauma due to osteoporosis or weakened bone. Patients may have sudden hip pain due to sprains or tears of the soft tissues from lower extremity trauma that occurs suddenly. Other causes of hip pain due to chronic inflammation like arthritis or tendonitis can come on suddenly or more slowly.

  • The hip joint is a ball and socket joint with the femoral (thigh bone) head sitting inside the acetabulum (socket). The acetabulum is surrounded by a rim of strong cartilage called the labrum. The femoral head is connected to the femur by the femoral neck. The hip joint is in the groin. The lateral hip bone is the greater trochanter. The hip joint is surrounded by a thick capsule. Numerous tendons attach on and near the hip that flex, extend, internally rotate, externally rotate, abduct and adduct the hip. Simply stated, the hip flexors are in the front of the hip and the hip extensors are located in the buttocks. Due to the shape of the joint and the strength of all the surrounding structures hip dislocations are unusual without high force trauma. Most patients who complain of their hip popping out are actually complaining of a snapping tendon.

  • The common causes of hip pain in middle age patients are arthritis, tendinitis, labral tears, or bursitis. Patients with arthritis will often complain of groin pain, and occasionally lateral hip pain or buttocks pain. Patients with bursitis will have lateral hip pain directly over the lateral greater trochanter. Labral tears will present as groin pain with possible locking or snapping. Tendinitis of the hip flexors will present as anterior hip pain with possible snapping. Tendinitis or muscle strains of the hip extensors will present as buttocks or posterior thigh pain. Occasionally this needs to be differentiated from sciatica or nerve pain radiating from the lumbar spine.

  • The physician will check the range of motion of the hip which may be restricted in an arthritic joint. Provocative maneuvers may further demonstrate labral tears or tendon injuries. Palpation of the anterior hip will often locate a flexor tendon injury. Palpation of the bursal sac at the greater trochanter on the lateral hip will confirm the most common hip bursitis. Palpation of the posterior hip will locate an extensor tendon or muscle injury. Examining the patient's gait can help determine the location and the severity of the injury.

  • An x-ray is often the first test ordered in the office when a middle aged patient presents with hip pain. The x-ray can help rule out a fracture. Most fractures are due to traumas and present to emergency rooms because the patient is unable to walk. Occasionally, stress fractures or low energy fractures will present to the orthopedic office and an x-ray will help confirm the diagnosis. An x-ray is the best test to evaluate hip arthritis. Although the x-ray will not show cartilage, it will show joint space narrowing, bone spurs, bone cysts, areas of sclerosis, and areas of bone impingement. An MRI is the best test to evaluate the labrum and the tendons. However, the MRI is usually only ordered if conservative care fails. Most patients with labral tears and tendon injuries will respond to conservative care and will not need an MRI. An MRI will be ordered sooner if a stress fracture that does not show up on x-ray is strongly suspected. Occasionally, a CT scan or Ultrasound may be ordered.

Treatment

  • 1) Pain relievers are often used to treat hip pain. Tylenol (acetaminophen) is likely the safest medicine as long as the patient does not have liver issues or a history of heavy drinking. Tramadol is a non narcotic pain reliever that can help hip pain but is not recommended for routine use. Narcotic pain medicines are not recommended for chronic hip pain.

    2) Non-Steroidal anti-inflammatory drugs are effective to treat chronic hip pain. In past generations putting every patient on 800mg of Motrin/Ibuprofen/Advil was routine but this is not healthy for most patients' kidneys, stomach lining, or heart/blood pressure. Healthy patients can tolerate this dose but their PCP should be aware they are taking it. Most patients only take Motrin for an acute flare for a few days or weeks. Naprosyn/Naproxen/Aleve are a twice a day option. Meloxicam/Mobic and Celebrex are once a day options. They all have similar side effects to Motrin but these side effects can be minimized with controlled dosing. Regardless you should not take them if you have been advised against it by your PCP, if you are on blood thinners, or you are taking another NSAID. In some patients a non steroidal anti-inflammatory cream is a better option.

    3)Supplements- there are many anti-inflammatory supplements such as glucosamine/chondroitin and turmeric that have benefited patients. Others have found relief or a decrease in symptoms from an anti-inflammatory diet.

  • Most patients with chronic hip pain will improve with physical therapy. It is the first line of treatment for most tendon injuries whether the tendon is inflamed, partially torn, or completely torn. Physical therapy will also help with arthritis. An arthritic joint often becomes weak and stiff. Improving the range of motion and strength in the joint can significantly decrease or relieve the pain. Therapy is the first line of treatment for labral tears in middle aged patients. Once a patient completes therapy they will be encouraged to continue a home exercise program to manage/prevent recurrence of pain.

  • 1) Steroid/cortisone injections are highly effective in treating trochanteric hip bursitis. They are also commonly used to treat arthritis. These injections go into the joint and will require radiologic or ultrasound guidance. Our practice does hip injections under fluoroscopic guidance at our surgery center. Steroid injections are not used commonly for tendonitis unless conservative care fails.

    2) Viscoelastic/artificial joint fluid/ gel injections that are used in the knee are not effective in the hip.

    3) Stem cell and Protein Rich Plasma injections- These injections have many growth factors which do not replace cartilage but they may help heal damaged cartilage. Insurance does not cover these injections and they can be expensive. There are minimal drawbacks from trying these injections besides the cost and the disappointment if they do not work.

  • 1) Hip arthroscopy: Hip arthroscopy involves using cannulas with cameras and small instruments to clean out or repair the joint. It is a procedure becoming more common as advances in technology and familiarity expand. The most common indication is labral tears in young active patients. It has expanded to labral tears and occasionally tendon injuries in active middle aged patients. Heavier patients, older patients, and patients with hip arthritis will not do as well. It is a technically challenging procedure due to the deep nature of the hip joint and the tight fit of the femoral head in the acetabulum so it is only done by orthopedists who sub-specialize in hip arthroscopy.

    2)Hip arthroplasty/Hip replacement surgery: The treatment for severe hip arthritis is total hip arthroplasty. Hip replacement has a 95% success rate with the implants remaining viable at 10 years. These success rates make it one of the most successful surgeries in all fields of medicine. Recent advances allow for many patients to have the surgery done at outpatient centers. Current debates are related to various implant choices and surgical techniques. There is no difference in long term outcomes between anterior or posterior surgical approaches. Despite the 95% success rate, complications can occur. Infections may require surgery to remove the entire implant. Loosening, fracture, and dislocations may require a revision procedure. Revision procedures are far more challenging with higher complication rates and lower success rates than primary procedures. This is why hip replacement should be reserved for patients with severe arthritis which is limiting their activities of daily living.

Prevention

Chronic hip pain is one of the most common reasons to see an orthopedic surgeon. After examining thousands of patients and looking at thousands of X-rays and MRIs we know that the severity of arthritis, tendonitis, or labral tears does not always correlate with the amount of pain. I will frequently say, “there are people out there playing sports with hips that look like yours”. We know that lighter patients who maintain strong and flexible hips can tolerate a higher level of joint damage. Ultimately, most chronic hip pain is a disease of chronic inflammation. If you decrease your chronic inflammation you will decrease your inflammatory pain. An anti-inflammatory diet can significantly decrease your inflammatory pain and many doctors encourage you to try it before proceeding with a hip replacement. Improving your overall fitness will improve your inflammatory pain. Improving sleep and stress levels will as well. We will frequently see patients with bone on bone arthritis who require minimal treatment because they have controlled their chronic inflammation. Some of these patients fell into this lifestyle while others consciously chose to pursue a healthier way to approach life.