Common Causes of Hip Pain
The hip, like most joints, is a very busy place. While someone may have pain in the hip area, there are many different sources of pain, which may or may not be the joint itself. It is important to differentiate these before initiating therapy, as your outcome correlates directly with an accurate diagnosis.
Problems in and around the hip can be broken into two categories, intra-articular (inside the joint itself) or extra-articular (pain in the hip area which doesn’t involve the hip itself).
Intra-Articular Hip Problems
Hip problems involving the joint itself can be related to the cartilage, the soft tissue structures such as the labrum, the ligaments involving the hip, or the lining (synovium ) of the joint itself. It is important to differentiate the source of the pain, as the treatments can be very different. Sometimes, we will have to use advanced imaging, such as an MRI, or an MR arthrogram, to differentiate these issues. Occasionally, we will have to use testing beyond imaging to differentiate these particular structures and the problems that they may have.
The smooth, gliding, surface of the joint itself is formed from cartilage. This is a fairly soft, smooth structure, which can allow for pain-free motion. This can become damaged either because of regular wear and tear (primary osteoarthritis) or trauma (post traumatic arthritis) or some form of inflammatory condition (rheumatoid arthritis). Ultimately, if the cartilage of the ball or socket becomes damaged, this can become a painful scenario. Most commonly, it is the simple addition of years of activity that can lead to degeneration of the hip joint itself.
If your cartilage is worn down, or damaged, this can become a painful scenario for you. Once this gets to a certain degree, the treatment options need to be considered. These can be as simple as anti-inflammatories, rest, avoiding the things that cause you pain. If this becomes more of a concern, then the treatment options include any one of a number of different types of injections, which can decrease the pain that you have, and reestablish her quality of life. If this does not work, then discussions of possible surgical intervention may have to be had. Specifically, total hip replacement, may be a surgical option that can be a very robust and long-standing solution to this particular problem. It will be important to have a full clinical workup as well as discussion with your surgeon regarding any and all treatments.
The labrum is a structure within the hip joint itself, this is a soft tissue structure which helps to deepen the socket, making it more stable. At times, in the setting of trauma or wear and tear, this can become damaged or torn. This can become painful scenario, which can lead to the inability to perform certain activities, or require treatment beyond simply conservative means.
While we are still learning about the labrum and the effects of a labral tear, this can be a very painful scenario, and it can require surgical fixation. To fix the labrum can require either an arthroscopic or a small open incision to repair the labrum, this can be performed on an outpatient basis, and although the recovery phase will require several weeks of limited weight-bearing and therapy, it has been shown to be consistently helpful in terms of returning someone to their previous level of pain-free activity.
Ligaments of the Hip:
The hip itself is held in place by ligaments, which connect bone to bone. If these are injured in the setting of trauma, or become contracted, this can become painful. Occasionally, these do require evaluation, usually with an MRI or an MR arthrogram. If this is performed and the symptoms are consistent with this particular issue, many times, we are able to treat this with conservative means, anti-inflammatories, physical therapy. If those fail, there are rare settings where we will have to repair the ligaments, or stabilize the hip otherwise.
Extra-articular Hip Problems
The structures which can cause pain outside of the hip can be within the region, or very far from that region. These can include the muscles, the gluteus complex, the hip bursa, the iliotibial band, the sacroiliac joint, the small muscles of the hip (short external rotators), pain referred from a low back issue, and many others.
Bursitis (Peritrochanteric Pain Syndrome):
Many people have already heard about bursitis. This is an inflammation of a small sac of fluid, which normally is meant to decrease pain and discomfort around the hip area. Occasionally, this can become inflamed and painful. What we have learned, is that bursitis is actually less likely than injury to the gluteus muscles, the muscles on the lateral aspect of the hip. These muscles are not necessarily torn, however they can be injured, strained, causing pain within the hip area. Oftentimes this is pain on the lateral aspect of the hip, it becomes painful when you are going from a sitting to a standing position. It is also painful to sit or lie on that side. There are also other structures that can become irritated in this setting, including the iliotibial band. It is important to differentiate which structure is either injured, tight, or otherwise having issues. Happily, this particular syndrome, is very amenable to physical therapy as well as injections of a steroid (cortisone) to decrease inflammation, and return you to your previous level of function.
Iliopsoas Tendon Injury:
One of the major tendons that runs across the front of the hip is the iliopsoas tendon. This is a large muscle which is classified as a hip flexor. This can be injured in the setting of athletics. Less commonly, this can be injured in the setting of a total hip arthroplasty, and may require treatment. This can cause even a loud snapping sound, if injured. Many times, we can treat this nonoperatively, and the use of physical therapy and anti-inflammatories as essential in the treatment of this. There are advanced surgical options should this become a persistent issue, will make that determination based on the origin of your injury.
Injury or irritation of the sacroiliac joint (the joint that joins the pelvis to the sacrum) can be called sacroiliitis. There can be an injury that initiates this, or there can be arthritis of that joint itself. This is amenable to many forms of nonoperative management, including injections very specifically into that joint and other modalities. If this becomes severe or unmanageable by nonoperative means, there are surgeries which can be performed that we will decrease motion to that area (fusion) to decrease pain.
One of the small muscles in the back of the hip, the piriformis, has been known to cause issues within the hip area, and can secondarily cause issues with the sciatic nerve. It is important to differentiate this, versus a low back issue which can also injure the sciatic nerve. The symptoms of this are buttock pain, pain with sitting or certain activities. This can cause symptoms which radiate down the leg. It will be important to perform a physical exam to differentiate this versus other forms of muscular or nerve injury.
Lower Back Pain:
The lower back is a culprit in many cases of leg and hip pain. There is a specific constellation of symptoms which we will explore, there are also tests that we can perform which include x-rays, MRI, injections, nerve conduction tests, which will help us to differentiate a hip problem versus a back problem. Oftentimes, there is a combined issue which may require treatment for both. Many times, this does not require surgical intervention. We will have to work with you regarding your clinical scenario to differentiate these sources of pain.