Sports medicine physicians and orthopedic surgeons see all kinds of injuries in the athletic population. One of the less common but very challenging areas of injury to evaluate is the hip. More specifically, the lateral hip (along the side of the upper thigh/buttock area) gets our attention today.
To help professionals involved with lateral hip pain in athletes, the authors of this article provide a review of the area anatomy. Besides the hip joint itself, which is very complex, there are various ligaments, muscles, connective tissue, bursae, blood vessels, and nerves to consider.
Suggestions are offered for the examination, which includes taking a good patient history and conducting a thorough physical exam. For example, there are six bursae in and around the hip that must be examined carefully. These structures are designed to keep tendons and other soft tissues from rubbing against the bone underneath. It is not uncommon for one or more bursae to become painfully inflamed.
Each muscle group must be inspected and palpated. Any changes in the way the patient moves or walks might be traced back to a specific muscle or muscle group. Posture, hip range of motion, and specific sites of tenderness provide helpful clues to what is going on.
Making the diagnosis is based on an understanding of what happened, how it happened, clinical presentation (signs and symptoms), and the results of specific tests. It’s really a differential diagnosis meaning the physician sorts through all the possible problems that could be present. Using the information collected so far, the doctor rules out those that don’t fit the description. Then further tests are done until the final diagnosis is made.
Some of the most common choices in the differential diagnosis include: hip pointer, greater trochanter bursitis, iliotibial band syndrome, snapping hip syndrome, tendon tears, and meralgia paresthetica. Let’s take a closer look at each of these conditions.
Athletes who collide with others or who take the force of a helmeted head into the lateral hip can end up with a hip pointer. This injury or contusion is visible as blood under the skin leaves a large bruise. It is treated with a leave it alone approach. Ice, rest, and compression help the body complete its natural course of healing.
Bursitis is best treated by finding out what is causing the friction in the first place and dealing with that problem. It could be tight, inflexible muscles, tendons, or fascia. Stretching, strengthening, and manual therapy under the supervision of a physical therapist may be advised. Or it could be a postural or alignment problem such as a leg length difference, unsupported flat feet, or even broken down running shoes.
Sometimes a tendon (e.g., the iliotibial band along the outside of the leg) snaps over the bone underneath. This condition is called iliotibial (IT) band syndrome or snapping hip syndrome. The IT band can be so tight that movement causes a pop that can be seen and heard. The athlete is taught how to avoid those movements and how to stretch the involved soft tissues. In chronic cases that don’t respond to physical therapy, surgery to release or lengthen the tight tissue may be needed.
That brings us to lateral hip pain caused by tendon tears. The tendons involved most often are from the buttock muscles (gluteus medius and gluteus minimus). Because of the way these muscles attach to the greater trochanter (part of the femur or thigh bone), tendinitis of the gluteal muscles can look just like bursitis or iliotibial band syndrome.
And finally, meralgia paresthetica must be considered whenever there is numbness along the front and side of the thigh. Meralgia paresthetica is caused by entrapment of the lateral femoral cutaneous nerve. This nerve can get pinched or compressed by tight clothing, after surgery to remove bone from the pelvic crest, a large belly associated with obesity, or in association with diabetes.
All of these conditions are considered self-limiting meaning they will eventually go away in time. Treatment is first with conservative (nonoperative) approaches. The most common plan of care is for oral anti-inflammatory drugs, rest, and physical therapy. The therapist will work on correcting postural issues or malalignment, stretching and/or strengthening, and modification of aggravating activities or movements.
The physician who can recognize and accurately diagnose hip problems in athletes is an important member of the sports team. A quick differential diagnosis and injury-specific treatment can get the player back into play faster and with fewer additional injuries.