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Injury/Pain

Everything You Need to Know About Hip Injuries

Overview

Your hips are strong and stable when healthy, but injury and certain conditions, like osteoarthritis and osteoporosis, both common in older adults, may affect the health of the hips.

For athletes, playing sports, running, falling, heavy impact and overuse can lead to hip strains, hip pointers, hip bursitis and something called femoroacetabular iimpingement (FAI).

So how do you avoid the hurt or bounce back from hip ailments? Keep reading—it's all here.

Chiceaux / flickr

By the Numbers

  • 5-9
    Percentage of high school athlete injuries that involve the hip
  • 10
    Percentage of injuries among NFL players involving the hip

Hip Pointer

A hip pointer is one sports injury in which you, the athlete, can probably make a diagnosis as quickly and accurately as a physician. You’ll know it has happened when you get hit or fall on your side, and the first thing that absorbs the blow is the outer part of what most people would call the hip bone, which is a misnomer. Actually, a hip pointer is a deep bruise, or contusion, on the top portion of the pelvis that can be felt on either side of the waistline. The distinguishing characteristic is hip pain, plain and simple.

It’s not a career-ender, but it is a painful injury that can keep you out of action for days or weeks if you don’t take care of it and if you rush back into training or competition before it has healed. “It is difficult to manage because the strong muscles that attach put constant stress on the area,” says Lyle J. Micheli, MD, Sports Medicine Director, Boston Children’s Hospital and Harvard Medical School.

How It Happens

A hip pointer is caused by a direct blow to the top portion of the pelvis, which is called the iliac crest. It could happen with a direct blow taken in a contact sport or when an athlete (skier, cyclist, for example) falls and hits the surface hard.

By the Numbers

  • 1 – 3
    Average number of weeks it takes to return to training or competition after suffering a hip pointer

Who’s At Risk

Athletes who participate in contact sports, especially those who wear little or no protective padding or equipment, are at highest risk. Football players are at the top of the list because 1) they often get hit often by an opponent’s helmet or shoulder pads, 2) they hit the ground hard or 3) both. Other athletes that are vulnerable are those who play hockey, soccer, rugby, or lacrosse, and those who ski and cycle.

Symptoms

  • Sudden pain on the upper, outside part of the iliac crest caused by a blow or a fall
  • Hip pain that gets worse with activities such as running, jumping, twisting, or bending
  • A limp
  • Tenderness in the top area of your hip
  • Limited range of motion at the hip joint
  • Possible bruising and/or swelling
  • Possible muscle spasms in the hip area

Initial Treatment

  • Rest 24-48 hours to prevent further damage. A hip pointer needs time to heal itself.
  • Apply ice packs for 15-20 minutes, 3-4 times a day for the first 24-72 hours, but don’t apply ice directly to the skin. 

Comeback Strategy

“A hip pointer is a contusion that will take some time to heal,” says Sue Falsone, director of performance physical therapy at Athletes’ Performance. “It is important to move the hip so it does not get stiff and lose range of motion, but you need to respect the healing process as well. Movement should be pain free. Aquatic therapy can often be helpful to maintain range of motion as the tissue is healing. It is also important to protect the area with padding when returning to sport so you don't continue to traumatize the area, creating a long-term problem.”

The pain from a hip pointer can last several weeks, as can pain when the bruised up comes into contact with something or somebody. Everyone recovers from an injury at a different rate, so returning to training and competition will be determined by how soon your hip recovers, not by how many days or weeks it has been since your injury has occurred. However, the condition usually heals within one to three weeks.

Start treatment as soon as possible. The longer you wait, the longer it will take to get better. If you return too soon, you might make the injury worse. Here are some prehab exercises:

How to Avoid This Injury

Most hip pointers are accidental events and cannot be prevented. Wearing protective hip padding appropriate for your sport gives some protection.

Movement Prep

Always warm up with a movement prep routine. Incorporate these exercises into your movement prep:

  1. Lateral Squats
  2. Forward Bound with Mini Band
  3. Lateral Bound
  4. Drop Step Skip

Hip Flexor Strain

Hip flexor strains can range from mild to severe, or in medical terms, from first to third degree. A first degree hip flexor strain means one of the hip flexor muscles has been stretched or slightly torn.

Geoff Ruddock / flickr

Second degree strains refers to a partial tear of the muscle or tendon, and in a third degree sprain, the muscle or tendon is completely severed—a rare event. When a tendon is pulled off the bone at the place where it is attached, it is called an avulsion fracture. Depending on the severity of the injury, recovery time ranges from a few days to months.

How It Happens

There are as many as six muscles involved with flexion of the hip, and any of them can be strained. But the one that gets the most attention is the iliopsoas, a hip flexor that can be strained when it contracts forcefully, especially when the leg is fully extended or prevented from moving. Kicking and sprinting are the most common movements that cause strained hip flexors, but bending at the waist will be difficult after the injury has occurred. Hip flexors can be overused, and overuse can lead to strains. Tight hip flexors may make an athlete more vulnerable to hamstring strains.

Who’s at Risk

Soccer players, especially when they take a blow while trying to kick, are at risk, as are runners during the “kick” phase of a race, martial arts athletes and cyclists. Any athlete who has weak or inflexible hip flexor muscles is vulnerable to this injury. Lack of flexibility, cold weather and an inadequate warm-up can increase the risk of a strain.

Symptoms

  • Pain in the groin area or front of hip
  • Lack of strength when trying to lift the knee against resistance (when there is a complete tear)
  • Possible swelling

Initial Treatment

  • Rest 24-48 hours to prevent further damage. A hip pointer needs time to heal itself.
  • Apply ice packs for 15-20 minutes, 3-4 times a day for the first 24-72 hours, but don’t apply ice directly to the skin.
  • Aspirin, ibuprofen, and naproxen may relieve pain.
  • Compression shorts or a wrap bandage may be helpful.
  • For second and third degree sprains, rest the leg that has been injured, use ice applications, and see a sports medicine physician.

Comeback Strategy

“Hip flexor strains requires that attention be given to the muscle’s antagonist (opposite mover), the gluteals,” explains Jennifer Lewis, Performance Physical Therapist at Athletes’ Performance in Phoenix, Arizona. “It is important for the glutes to not just be strong, but to be neutrally activated. This means that the muscle is ‘warmed up’ and turned on through proper prehab and movement preparation activities.”

“Also, proper stretching and lengthening exercises are appropriate, depending on the stage of the injury. Pay special attention to proper core stability so that the core maintains a stable spine and provides a solid base for movement of the hip flexors.”

Athletes need two to seven days to recover from a mild sprain, one to two weeks for a second degree injury and four to six weeks following a complete tear. Keep in mind that rehabbing the injury requires good knowledge of why it occurred in the first place (tissue overload, poor pillar strength, a slipping/ traumatic event). If the pain began for no apparent reason, see a medical professional. Long standing groin or hip flexor pain can be indicative of other hip problems and should be cleared by a doctor. You might be advised to use crutches if the pain is severe or movement difficult. Once you are reasonably mobile, cross-training (swimming instead of running, for example) in a sport or activity that does not challenge the hip flexors is a way to stay in shape during the recovery period.

You’ll know you are ready to return to action when you have a full range of motion with the affected leg, when strength on the injured side is equal to strength on the opposite side, and when you can walk or run without limping. Physical therapists might also require you to perform other sport-specific movements. Lewis provides these examples of exercises that can be used during rehab include:

How to Avoid This Injury

Any muscle or muscle group that has been injured previously is more susceptible to a subsequent injury. Observe the ten percent rule: do not increase exercise intensity, duration, or frequency more than ten percent a week. Below are examples of movement prep exercises, but any of the exercises listed under Comeback Strategy are also appropriate for preventing a hip flexor strain.


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Hip Bursitis

Bursae (the plural for bursa) are small sacs of lubricating fluid located at various joints in the body. The sacs are particularly important in the elbow, shoulder, knee, heel and hip joints. They act as shock absorbers and cushions between bones and the surrounding soft tissue. If the sacs become irritated or inflamed, the condition is called bursitis.

Jeff Gross / Getty Images

There are two major bursae in the hip joint: one on the outside tip of the hip and the other in the buttocks area. Hip bursitis is the most frequently reported cause of hip pain and, but it is more likely to affect middle-aged and older adults rather than younger athletes and exercisers, and women are more often than men.

How It Happens

“Among athletes, bursitis often involves excessive irritation of a bursa that lies under the iliotibial band or the muscle that flexes the hip,” says Jennifer Lewis, performance physical therapist at Athletes’ Performance. “With friction, pain will often be in the front of the hip instead of the typical outside hip pain that occurs in non-athletes. In cases where outside hip pain does not respond to treatment, the pain may be coming from another site, such as the lower (lumbar) part of the spine.”

Regardless of the location, hip bursitis happens when one or more bursa sacs are irritated and become inflamed due to trauma (getting hit and falling on the hip), overuse (in distance runners, for example), hip bone spurs, poor posture (caused by scoliosis, for example), arthritis or leg length differences.

By the Numbers

  • 150
    Number (approximate) of bursa sacs in the body
  • 2
    Number of major bursae in the hip area
  • 80 to 20
    Ratio of outside-tip hip bursitis in women, as compared to men (according to one study)

Who’s At Risk

Data is limited, but distance runners appear to be at higher risk for hip bursitis than other athletes. Hip bursitis in other athletes is less common, but when it does occur, those who play contact sports such as football and hockey are more likely to sustain blows to the hips that could lead to hip bursitis.

Symptoms

  • Pain at the outside point of the hip that may extend down to the outside of the thigh muscles
  • Early stage hip pain that is sharp and intense; later stage “achy” pain felt over a wider area
  • Hip pain that is worse at night, when lying on the side of the injured hip, and when getting up from a chair
  • Increased pain when walking long distances, climbing stairs and squatting
  • Tenderness to touch

Initial Treatment

  • Apply ice packs for 15-20 minutes, 3-4 times a day.
  • Avoid or limit the activities or movements that cause the pain for 2-3 days.
  • Aspirin, acetaminophen, ibuprofen and naproxen may relieve pain. Aspirin, ibuprofen and naproxen may relieve pain and reduce inflammation.
  • Use crutches if pain makes walking difficult.

Comeback Strategy

The evidence supporting formal physical therapy for hip bursitis is limited, but there is plenty of anecdotal support for measures such as ice, heat and other treatment strategies.

Prehab

Incorporate these prehab exercises into your comeback routine:

  1. Soft tissue massage with Soft Tissue & Stability Stick (to muscles on the front and sides of the hip, 2-4 minutes, 3-4 times a day)
  2. Glute Bridge
  3. Hip Rotation - Sidelying - External

How to Avoid This Injury

  • Wear athletic shoes that provide adequate cushioning in the soles and side-to-side support.
  • Use protective padding to prevent hip injuries that might lead to bursitis.
  • Avoid or limit running on banked surfaces.

Movement Prep

Incorporate these movement prep exercises into your warm-up routine:

  1. Hip Flexor Stretch - Kneeling
  2. Leg Cradle
  3. Forward Lunge Elbow to Instep

Femoroacetabular Impingement (FAI)

If femoroacetabular impingement (FAI) is not a term you recognize instantly, pronounce easily or use daily, you’re not alone. But FAI is a condition that affects athletes in many sports and appears increasingly in medical literature, as well as on sports pages. Think Alex Rodriguez and hip surgery.

Phillie Casablance / flickr

“FAI is a condition in which abnormal bone growth on both the femur (the large bone in the upper leg) and the acetabulum (the socket part of the pelvis) repetitively contact each other,” says Marc Philippon, MD, the orthopaedic surgeon who operated on Rodriguez. Other high-profile athletes who've had orthroscopic surgery to correct FAI include Greg Norman, Mario Lemieux and Kurt Warner. “The constant rubbing damages the articular cartilage on the round head of the femur and the labrum (the rim around the hip socket).”

How It Happens

The hip is a ball and socket joint. For reasons not completely understood, some people develop excessive bone tissue at the top of the femur and around the edge of the hip socket. These people are not born with FAI. It appears to develop early in life as the person grows.

The movement that aggravates FAI is a forceful rotation of the core, including the hips. The longer that repetitive rotational movement occurs over a period of years, the more irritated the area becomes, the more pain can be felt because of bone to bone contact, and the more likely osteoarthritis will develop. When enough cartilage has been worn away from the top of the femur, the athlete will feel the pain.

FAI comes in two forms, cam and pincer. Mospatients have a combination of the two. Cam impingement results from excess bone located at the neck (top) of the femur. Pincer impingement is caused by excessive bone tissue on the acetabulum/socket of the pelvis.

By the Numbers

  • 10-20
    The percentage of people in the general population who have FAI
  • 93
    The percentage of professional athletes, according to a study of 45 men and women, who returned to their sports following orthroscopic surgery for FAI.
  • 78
    The percentage of pro athletes (same study) who remained active a year and a half after orthroscopic surgery

Who’s at Risk

Philippon calls FAI “a disease of active people.” The greater the number of physically active people, including pre-teens and adolescents, the greater the number of FAI cases. Almost any athlete whose sport requires forceful body rotation can develop FAI, but only if that person is among the 10-20 percent of people in which the condition exists. The rest don’t have to worry about it.
Golf, football, baseball, volleyball, soccer, hockey, lacrosse, field hockey, martial arts, rowing and tennis are the sports most likely to aggravate the FAI. FAI incidence among ice hockey goalies who use the “butterfly technique” (knees in, lower legs and feet down on the ice and out) to stop shots has been described as “epidemic.” Deep squatting performed in power lifting can also irritate the area.

Symptoms

  • low back, pelvic and buttocks pain
  • side of hips pain
  • stiffness or pain in the groin region in front of the hip
  • increased pain or stiffness after athletic activities and long periods of sitting

Initial Treatment

Th only thing an athlete can do for short-term relief is to rest, avoid excessive hip rotation movements and use over-the-counter medications, such as aspirin, ibuprofen, acetaminophen or naproxen to relieve pain and reduce inflammation.

Comeback Strategy

Long-term treatment has involved open surgery and is generally successful, but requires an average of nine months for the patient to return to sports. Arthroscopic surgical techniques developed by Dr. Philippon have proven to be even more successful, getting patients back to their sports in as little as three months. Here are some prehab exercises that might be prescribed by an orthopaedic surgeon and supervised by a physical therapist to speed up the recovery process:

How to Avoid This Condition

FAI is not preventable. However, there are sports that bring out the worst in the condition. Avoiding those sports is not an acceptable option for most athletes, so developing a training program to minimize the risk of permanent damage is essential. Below are some movement preparation exercises to strengthen the muscles supporting the hip joint and to make that joint more flexible.

Jim Brown, Ph.D. has written 14 books on health, medicine, and sports. His articles have appeared in the Washington Post, New York Post, Sports Illustrated for Women and Better Homes & Gardens. He also writes for the Duke School of Medicine, UCLA School of Medicine, Cleveland Clinic and Steadman-Hawkins Research Foundation.


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Tags: Soreness, Injury, Prehab, Rehabilitation, Hip Pain, Lower Body, Field Hockey, Hip, Pain, Injury Prevention

References

  1. Sue Falsone, Director of Performance Physical Therapy, Athletes' Performance
  2. Jennifer Lewis, PT, ATC, Performance Physical Therapist, Athletes’ Performance, Phoenix, Arizona
  3. Lyle J. Micheli, author, The Sports Medicine Bible for Young Athletes (Sourcebooks, Inc.)
  4. American Family Physician
  5. University of Michigan Health System
  6. American Academy of Orthopaedic Surgeons
  7. American Family Physician
  8. Cleveland Clinic
  9. MD Consult Preview
  10. MedicineNet.com
  11. Marc Philippon, Orthopaedic Surgeon, Steadman-Hawkins Clinic
  12. The Children’s Hospital, Aurora, Colorado
  13. Orthopaedia: Collaborative Orthopaedic Knowledgebase
  14. Journal of Knee Surgery, Sports Traumatology, and Arthroscop
  15. University Sports Medicine, Buffalo
  16. Sports Medicine Bulletin

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