Orthopedic surgeon and sports medicine specialist Stephanie Wong, MD, takes you on a “tour of the hip” in this straightforward guide to acute and chronic hip injuries frequently seen in clinic. She provides keys to distinguishing each condition – including subtleties of pain location, typical patient factors, and physical exam tests that facilitate diagnosis – and breaks down nonoperative and operative treatment options.
So my talk today will be on common hip conditions and so we're gonna kinda take a tour around the hip and talk about um some key conditions that I see frequently in clinic. In terms of the key history questions, the things that I really kind of try to dial down on are the chronicity of injuries, so whether it's a kind of chronic or more of an acute injury, um, the mechanism of their injury if they had one, and then finally location. Location, I think is one of the most important questions I ask um patients about, um, as part of my history taking. So if the patient has anterior or groin pain, there are a couple of different musculoskeletal causes of that. So if they have intraarticular or deep hip pain, um, or deep groin pain, I think about conditions such as hip arthritis or femoral acetabular impingement, which we'll go over in more detail in a moment. If they feel like the pain is more superficial on the surface where they can kind of feel it with their hand or pushing down on the muscle, that might be more consistent with a flex, hip flexor or an adductor muscle strain a little bit more medially. Um, if they point to the lateral hip as uh that location of pain, I think about conditions such as trochanteric bursitis or trochanteric pathology as well as IT band syndrome or snapping hip. And then finally, if they have posterior pain or buttock pain, I think about SI joint pain, hamstring injuries, or referred pain from the lumbar spine or radicular pain such as a sciatic nerve type, um, condition. And we'll go through kind of all of these and again kind of take a tour around the whole hip so we can talk about all the different types of pathologies that you might see. For femoral acetabular impingement, what this is, is essentially where you have abnormal bony anatomy that gradually forms during development. So we think that this is a process that occurs as bones develop, and you can see here on the X-ray, um, here's the proximal femoral phis, and just below that, you see kind of a bump of bone here. And you can imagine that this bump of bone or what we call a cam deformity. When you flex your hip up, this bump can actually bump up against the socket in the labrum, causing a labral tear, um, and we call this pinching, um, of the labrum impingement. This condition affects um patients from a wide range of ages from about 15 to 45 or so. Most of the time patients with this condition describe a chronic type pain. So they usually will say, you know, the pain has been going on for months, maybe even years. There's typically not a specific injury for it. Uh, we know that there's a very high prevalence in athletes, so studies have shown that You know, 75% of elite hockey athletes will have this type of cam-type appearance on their X-rays. Um, and about 90% of athletes at the NFL combine had at least one sign of impingement on their X-rays. Um, now, these aren't always symptomatic, but they are very prevalent. And the reason why we care about this condition is over time it can cause intraarticular injury to both the labrumus and cartilage as this bony bump either on the femoral head side or if they have a bony impingement on the socket side, um, kind of, you know, cause that damage and over time, this can lead to hip arthritis. So here's a nice diagram showing the different types of impingement. So you can either have impingement on the socket side which we call the pincer. Um, this pincer lesion is basically over coverage of the acetabulum, and you can see here if the hip flexes up, that would pinch, um, up against the femoral head neck junction as well as impair the labrum. And then alternatively, we have a cam-type deformity or cam lesion where there's a bump on the femoral head side. This can again cause issues with the labrum which is this black triangle on the corner here. Some patients have a mixed type picture where they have both a pincer over coverage as well as a cam bump on the femoral head, um, and some patients just have one or the other. Now looking more specifically at the hip labrum, it's a protective ring of fibrocartilage that kind of goes around the perimeter of the socket. It, um, it's kind of like a gasket seal and it contributes to both the hip stability as well as the suction seal for the hip joint. This arthroscopic picture shows the labrum which is being held up by the metal probe, um, and there's actually a tear of the labrum in that region and then the cartilage has kind of peeled away from the bone in that area. Um, and so labral tears are actually very, very common, so about 90% of patients or more with impingement have labral tears. But interestingly, so do patients that are asymptomatic. So patients that might get hip MRIs for other reasons such as, you know, posterior pain or lateral hip pain, about 70% of those patients have labral tears as well. And then when we see an isolated labral tear in patients that are over age 35 or so, this could be a normal change or degeneration of that tissue. So I think about the labrum, similar to how we think about the rotator cuff in patients as we get older, that there are some changes to those tissues in asymptomatic patients um on the MRI. So we really need to think about does the clinical picture match um their MRI findings. So in terms of clinical picture, this is how I think about for the history and exam. But typically patients will say they have groin pain or pain kind of in the front pancrease. They may show you the C sign and if they put their hand on their hip and they say it feels like it's deep and kind of in this distribution that would be consistent with FAI, they might have pain that's worse with sitting as well as worse with activity. The classic physical exam maneuver is a fader, which stands for flexion, a deduction, and internal rotation of the hip. This is very simple to do in the supine position. You passively flex the hip and knee up, and then you rotate the foot out, which in effect rotates the hip in and then you add up the hip a bit as well. Um, reproduction of their deep groin pain with this maneuver would be consistent with impingement. For X-rays, we get the classic AP pelvis to look at um the frontal view and then some sort of lateral. I prefer done lateral but really any lateral of the hip is acceptable to show that um cam deformity if they have one. and the x-rays are very useful to number one, rule out arthritis because arthritis can prevent similarly to impingement, um, and also to evaluate for the presence of a pincher cam lesion. Finally, if you have a patient who's, you know, tried non-operative management such as anti-inflammatory, physical therapy, and they're still having pain, you might consider an MRI. Um, uh, MRI without contrast for a 3 Tesla machine is acceptable for imaging the labrum and for imaging impingement. If it is a 1.5 tesla machine, then I usually will do an MR arthrogram. That's where they inject dye into the hip. Um, it looks like this, um, and so on this picture here, you can see the large dye pool and that just helps show the labral tear a little bit easier. The labrum in this picture is the black triangle off to the side and then the red arrow is pointing to a cleft of fluid between the acetabulum and labrum, and that's consistent with the labral tear. You can also see a large cam deformity in this patient, so you can imagine when this patient flexes their hip up, this bony prominence is gonna bump up against the labrum and over time can cause, you know, progressive tearing of the labrum and damage to the cartilage. So I always, um, you know, start patients with a course of non-operative treatment if they present to me with impingement. Um, so physical therapy can be quite effective for core as well as pelvic and gluteal strengthening, and then a steroid injection into the hip joint is a reasonable thing to consider, especially for those patients where the diagnosis may not be crystal clear as a diagnostic, um, test, as well as those patients that might have a little bit of early arthritis or early joint space narrowing, um, if they have a little bit of a mixed picture with impingement and arthritis, that would be reasonable. In terms of operative management, um, hip arthroscopy is an option for these patients, so we're going inside with a camera and then doing any la repair which is pictured in this diagram here and then trimming down the bone, um, if it's prominent. So we can do this either on the, um, socket side if they have a pincer lesion or on the femoral head side if they have Um, a cam lesion. So this diagram up here on the right shows some stitches through the labrum that's securing the labrum back up to the socket. Um, the acetabular cartilage is seen here in the distance, and then if you look at the images towards the bottom, um, initially you can see a big bump or cam deformity here, and then the postoperative X-rays, that's been nicely kind of trimmed back so that area of bone will, will no longer bump up against the labrum. All right, so switching gears a bit, um, to another very common injury, muscle strains. Muscle strains are probably one of the more common injuries that we see affecting the hip and pelvis, um, and these occur at the muscle tendon junction. Um, they're most prone to, uh, muscles that cross two joints, so you can think of, for example, the hamstring where it crosses both the pelvis and then the knee. So that would be an example. Um, and they're typically an acute injury, so the patients will describe, you know, maybe they were doing a sporting activity or maybe they had a fall, um, but they'll have some sort of mechanism. Um, anteriorly we think about the hip flexors or ileoso as as injuries, um, that or muscles that can be strained as well as the quadriceps group. Um, medially, the adductor, so people would typically describe a little bit higher up, kind of far medial groin pain with this. And then, as we mentioned before, hamstring strains kind of in the posterior muscle belly of the hamstring. The non-operative treatment is really the mainstay for muscle injury, so, you know, again, that would be in the muscle belly itself. Um, I usually recommend RICE, so rest, ice, compression, NSAIDs. Um, gentle range of motion stretching is encouraged just so the muscle doesn't get too tight. Um, here's a good picture of, um, a patient doing some icing of the quadriceps while stretching it. Um, so this is highly encouraged and then a gradual kind of progression to some light strengthening once the pain has improved. Depending on the grade of injury, return to play or sports is usually about 1 to 4 weeks, but I think a lot of these patients do benefit, you know, from some form of physical therapy just to help them along the recovery of this process. Now, let's look at the lateral hip. So the structures in the lateral hip include um the gluteus medius, so that's the muscle there coming off the back of the pelvis and then it attaches, you know, over on the greater trochanter. Um, starting at the greater trochanter, then you have the IT band which takes off and then runs down the lateral aspect of the thigh. Um, in this diagram, you can see the inflamed bursa. So the bursa is just an area of connective tissue which can become inflamed. I tell patients that it feels, it's bursas are kind of like your body's internal knee pads or hip pads or elbow pads like back in the day when you used to rollerblade, and they can become inflamed and swell up if that area is prone to a lot of friction or if you bump it or have an injury. Um, so this is the same type of bursa you might have, you know, in the front of the knee, for example. So if patients have lateral sided hip pain, it could be due to trochanteric bursitis or inflammation of that bursa. Um, could also be due to a gluteal tendon tear, um, which we'll talk about in a moment. Um, IT band syndrome is very, very common as well, um, or tight IT bands, and then finally, external snapping hip or where the IT band kind of rubs over the greater trochanter, that's also another cause of this lateral hip pain. So looking at trochanteric bursitis, here's just a few more kind of picture diagrams looking at the bursa itself. There are multiple bursa, um, and this is a very common condition, most common in females probably ages 40 to 70, but of course can present in other patients as well. Classically, patients will describe pain over the lateral hip as well as pain with sleeping right on that side because that's putting pressure right over the trochanter and the bursa. They will be tender to palpation, so you can have them lie lateral decubitus and then feel right over the bony prominence that is the trochanter, but they shouldn't have any hip abduction weakness. So if you ask them to do a side leg raise and abduct their leg in the air and you give them some resistance, they shouldn't be weak with that. Otherwise, you should be worried about a gluteal tendon tear, which we'll talk about. Um, the MRI here with the blue arrowhead over the left hip shows a lot of fluid within the trochanteric bursa, and this would be consistent with bursitis. In terms of treatments, um, most patients get better with non-operative treatment for bursitis, um, and I usually recommend physical therapy, especially for ITB and stretching. They also have myofascial decompression techniques such as cupping that they can offer the patients, and you can also try a steroid injection right into this inflamed bursa. Um, I do the steroid injections for the trochanteric bursa based on landmarks. So I have the patient bilateral decubitus and then palpate the area that's maximally tender and you can kind of fan out the injection into that space. There are also ultrasound-guided injections that are a little bit more targeted to the specific facets of the trochanter if you're interested in referring out for that. Um, in terms of operative management for those who've tried everything else, um, we can go in arthroscopically and essentially remove all the inflamed bursa and also window the IT band or create a little hole in the IT band that does typically help with patient's pain, um, if all else fails. Now I mentioned gluteal tendon tears. I think of these as kind of like the rotator cuff but of the hip. Um, these tendon tears can either be acute but more commonly are chronic and again, often affects, um, women ages about 50 to 70. Um, and the difference is that these patients will have both trochanteric pain but they'll also have weakness with hip abduction. You might see them limp or they might have a positive Trendelenberg sign. Um, that's a very simple test where you have them do a single leg stand. If the contralateral pelvis drops down towards the floor, they can't keep their pelvis level, then you might be concerned they have a gluteal tendon tear. Here on the MRI you can see again some white fluid, but the white fluid's filling the gap where you see the gray muscle and tendon is not attaching down to the bone. So this fluid gap is consistent with a gluteal tendon tear versus the prior MRI that I showed you. The fluid was kind of sitting like on top of the tendon or to the side of the tendon rather than within the area that the tendon is itself. For gluteal tendon injuries, um, I do try a course of non-operative management first, which includes, again, physical therapy. You can consider a corticosteroid injection to this region. There's some evidence that, um, PRP might be helpful or platelet-rich plasma. Um, there was a small randomized control trial of about 40 patients where they showed that leukocyte-rich PRP, um, performed better than steroid injection at 3 months for, um, both patient reported outcomes and improvement in pain. Um, that being said, I don't typically try more than maybe one steroid injection to this area just because I worry just like with the rotator cuff that the quality of the tendon might degenerate or deteriorate over time with repeated injections. So it might be worthwhile to try one, especially if There's a high grade or partial tear on the MRI, um, in terms of injections, but if they continue to limp and be really painful and weak, then I do talk to them about surgery, which is either endoscopic, so through a camera or open repair. And again, think of this just like the rotator cuff of the hip. The rehab is hard. Um, it's about 6 weeks on crutches with a brace just like you would for rotator cuff. Um, but normally after the recovery, patients are quite happy, um, and they can know, you know, they go back to walking without a limp. Um, so be on the lookout for these because I think that these are, these are sometimes, you know, hard to catch, um, and patients may be treated for bursitis for a long, long time before we realize they have a tendon tear. All right. Then, you know, for IT band, that's very common, you know, affects a wide range of patients and they might describe kind of this chronic lateral thigh pain kind of running down the side of their thigh or even kind of right proximal to their knee joint. Um, very common in patients who are active, so runners and bikers especially. Um, they might have snapping or tightness over their trochanter, and so that's where the IT band basically snaps back and forth as it rubs on the greater trochanter, and we call this external snapping hip. Um, the treatment really, most patients get better with non-operative management, so anti-inflammatories, and then treatments aimed at, um, loosening the IT band, so stretching, myofascial release with things like cupping, foam rolling. Um, and then similar to trochanteric bursitis treatment, the treatment, um, operatively would be going in with a camera endoscopically and putting a little window or cutting a little window out in the IT band, and this typically will take care of the snapping hip or, um, snapping sensation to get over the trochanter. All right. And then now let's move along to kind of the posterior region or back of the pelvis and hip. Um, this pain can again be both acute or chronic, so I have seen patients come in with posterior pelvis pain from an injury or even like, for example, an insufficiency fracture. Um, it can also be chronic, for example, in the setting of inflammatory arthritis, such as ankylos. spondylitis or SI joint arthritis. Um, in this, uh, x-ray, um, let me see if I can show you. There is some kind of sclerosis or increase in the white area, kind of surrounding both of the SI joints. So sclerosis is a little bit non-specific, but it can indicate either an inflammatory arthropathy or arthritis in that region. Um, and patients will be very clear and they'll kind of point right over the SI joint. So I encourage you to try to kind of find the SI joint on your own at home. Um, you can, you know, walk your hands down the middle of your lumbar spine and then over the back of the pelvis. You can actually usually feel this in most patients. So if they point right there and they're tender over the SI joint posteriorly, they might have pain originating from this joint. Um, on exam, classically, they're positive, um, favor, so stands for flexion, EB duction, and external rotation. So if you put them in kind of a figure 4 position, that'll actually compress the SI joint of the contralateral side. So it reproduces their posterior pelvis pain, that would be consistent with SI joint pathology. Um, a couple of different treatments in terms of non-operative options. So, um, physical therapy can be helpful for core and low back strengthening and can offload the SI joint. Of course, anti-inflammatories are also an option. You can inject steroid into the SI joint. It is difficult to get into because the ligaments are very, very strong. So this is typically one that I refer to my partners to do fluoroscopic guided injections. And then radiofrequency ablation is also an option, so that's where they go in and burn the nerves that can be causing the pain in the joint. Um, typically, most of my colleagues that do these procedures would have them try the steroid injection first, if that helps but it's temporary, they can consider an ablation procedure, um, for pain relief. Um, operative options. This is not performed very commonly, but I just wanted to put it in there just in case you've seen this before in some of your patients. But SI joint fusion is a procedure that some do, not very common. The evidence is a little bit limited as to how effective this is, but essentially you're putting a bolt across the joint. Um, some would argue here that the SI joint doesn't have a lot of movement to begin with, so what exactly are you fusing? Um, and then the spine surgeons I know who do this procedure, most of them believe that, you know, as you remount the area and then replace it with metal, that's probably doing something similar to an ablation where you're kind of deadening the painful nerves of the joint. So, just, you know, one option that's out there that I wanted to bring up in case you see in your clinical practice. All right. So one of the conditions I see pretty frequently is proximal hamstring rupture. And these are, you know, ones that you really wanna be able to differentiate between this, um, tendon rupture off of the bony origin. You want to differentiate this from a muscle strain. And so the way to do that is patients will often complain of some acute injury. It's usually some sort of awkward fall. They'll describe like, I was water skiing, I needed the splits. I slipped and fell on ice, which is not so common here in the Bay Area, but maybe if they They were up in Tahoe or I fell on a wet slippery floor, my legs went apart and did the splits. Um, and they have a lot of bruising. So some patients will, if it's a chronic injury, they might bring in pictures on their phone where they show you extensive bruising like this patient's, um, right thigh in the photo. Um, They will often describe buttock pain, pain with sitting, even cramping in the muscle belly itself. Um, usually patients that have muscle strains in the muscle belly, they'll have more pain kind of like focally in the mid mid portion of the muscle, um, and tenderness kind of focally. They won't be kind of extensively bruised, and they usually don't have quite such a dramatic, um, injury mechanism. Um, the patients with proximal hamstring ruptures will have pain if you palpate, so I have them go prone, and I always put them in short so I can actually see. But I'll feel up high in the ischium or right where their sick bone is. They're usually quite exquisitely tender there. Um, and then I also check in this position resisted knee flexion and resisted hip extension. So I do this by having them, um, flex their heel in towards their buttock. I'll check the good side and then compare it to the injured side. And then with their knee in that flex position with their foot kind of pointed toward the ceiling, I'll ask them to try to kick the ceiling with their foot to lift, extending the whole hip off the table. Um, usually if they have a rupture, they're not able to do that or they'll be significantly weak. Um, I always get X-rays in these patients, a pelvis AP at least just to rule out any avulsion fracture or fracture of the ischium. And then I have a low threshold to get, um, an MRI of the hamstring. So it's usually either termed MRI femur or MRI hamstring in your ordering, um. You don't want to do just a hip or just a knee cause it's not going to capture kind of the whole thigh. So here is a nice kind of coronal looking at the right pelvis. This bone at the top here is the ischium, and you can see here the ends of the tendon. The tendon should normally attach all the way up here. So this is a full thickness, you know, retracted tear of a couple of centimeters, and then all the white is just fluid and edema just from the acute injury, a hematoma, um, and things like that. Um, non-operative treatments are considered for patients that only tear one tendon or maybe have a two tendon tear that's not very retracted, but if they have all three tendons torn, we would generally recommend repair for those patients, especially if they are active and young and healthy. Um, So don't miss this, um. In terms of referred to radi radicular pain, so I see a good amount of this in my clinic as well. Um, some patients will describe hip pain when they really actually have pain from either their lumbar spine. Um, or, you know, compressed nerve from a, you know, disc herniation or lumbar radiculopathy. Generally, older patients, um, will describe this with degeneration of, you know, their lumbar discs, for example. So I tend to ask them about if it's not, if it's not classically, um, their presentation is not classic for Any of the pathology I've described earlier, so groin pain, lateral hip pain, buttock pain, SI joint pain. I start asking them about, do you have low back pain? Do you have pain that radiates all the way down your leg, all the way into your foot? Any numbness or tingling in the feet? So these are kind of tip-offs in the history that make me think maybe this problem is not from the hip joint itself but maybe referred to radicular pain. And then of course, treatments just based on the um diagnosis but would include things like physical therapy, epidural, or transaminal steroid injections depending on the location of the nerve compression. Um, and then that's all I have in terms of content, but I'm happy to take any questions in the Q&A and then I also wanted to share some slides. These are my excellent colleagues, um, who also take care of various sports medicine conditions. Um, so please feel free to contact any of us for any of your sports medicine needs. And then here is my information. Here's my UCSF email as well as my cell phone. If you have any questions or just wanna run something by me or have something urgent that you want to get in, just feel free to reach out, um, as well as our referral contact information on the right-hand side of the screen.
