By: Macklin Iliff
Hip pain is common in adults and often causes functional disability. Among adults over 60 the incidence of hip pain is 12 to 15 percent.1 There is quite a variety of causes of hip pain. Hip joint labral injuries and synovitis are common causes of hip pain in younger adults, while osteoarthritis becomes more common with aging. This blog focuses on some of the most common causes of hip pain including lumbar spinal stenosis, osteoarthritis, labral tears, femoroacetabular impingement, greater trochanteric pain syndrome, and sacroiliac dysfunction. Some common signs and symptoms for these conditions and treatment options will be discussed as well.
Lumbar stenosis is the narrowing of the central spinal canal, intervertebral foramen, and/or lateral recess within the lumbar spine resulting in progressive nerve root compression. It is commonly caused by degenerative joint disease and most often occurs in middle-aged and elderly individuals. Lumbar stenosis causes load-dependent lower back pain that radiates to the buttocks and legs. Lumbar extension and walking exacerbates the pain, while lumbar flexion improves symptoms. Patients may also have a wide-based gait, reduced lower extremity reflexes, or an abnormal Romberg test. MRI is used preferably to confirm the diagnosis. Treatment initially involves conservative measures such as NSAIDS and physical therapy. Another treatment modality is image-guided epidural steroid injections. The MILD procedure has shown to be a useful treatment modality as well. In this procedure, a port is made into the spinal canal and tissues and bone that are causing the compression can be removed.3 This relieves pressure on the spinal nerves to relieve pain in the back, buttock, and hips with standing and walking. Another advanced treatment option if conservative management has not been beneficial is called a Vertiflex procedure. This procedure involves implanting a spacer between spinous processes to relieve the pressure on the spinal nerves. Finally, the most aggressive form of treatment is laminectomy surgery where the back part of the involved vertebra is removed thereby relieving the spinal compression. This procedure can be combined with vertebral fusion for patients with an unstable spine. 4
Osteoarthritis is a disabling joint disease characterized by degeneration of the hip joints that can have various causes, most notably advanced age and overuse. It mainly affects weight-bearing joints and joints that are heavily used, like the hip. Major risk factors for osteoarthritis include advanced age, obesity, previous injuries, and asymmetrically stressed joints. In early stages, patients typically report a reduced range of motion, joint stiffness, and pain that is aggravated with heavy use. As the disease advances, persistent pain may also be present during the night or at rest. Initial treatment starts with exercise and weight loss.5 Pharmacotherapy can include topical or oral NSAIDs. Although, these treatments should only be used as a short-term treatment in symptomatic patients. Long-term therapy is associated with many adverse effects. Intraarticular steroid injections can provide local, short-term relief in some patients. Regenerative medicine treatments such as stem cells and Platelet Rich Plasma (PRP) are an option for patients who have mild to moderate osteoarthritis. If conservative measures fail, surgical procedures such as arthroscopy and arthroplasty could be indicated. Arthroscopy involves debridement and lavage of the joint. Arthroplasty is a complete or partial replacement of a joint using an endoprosthesis.
Labrum tears occur most commonly in athletes and active adults. An intact labrum seals the central portion of the hip joint from the periphery, thereby keeping synovial fluid in the central compartment and creating negative pressure within the joint, which enhances stability and resistance to femoral head subluxation. Thus, any disruption of the labrum adversely affects the health of the articular cartilage and joint stability. Tears of the acetabular labrum generally occur from two possible mechanisms: 1 a single, acute episode of significant trauma, most often involving forceful resistance of hip flexion while an athlete is kicking or running, or 2 repetitive microtrauma in a hip with chronic, degenerative bony changes.6 The most common sign of labral tear is pain with hip flexion. The tests that elicit pain most often are repeated hip flexion, hip flexion against resistance, and FADIR testing. The most accurate imaging study for diagnosing labral tears is an MRI. Initial management of labral tears consists of activity modification and physical therapy. Strengthening of the pelvic and lower extremity muscles helps to stabilize the joint and correct abnormal pelvic tilt, relieving some of the abnormal stress placed on the labrum. If physical therapy fails, arthroscopic surgery is indicated. Surgery should be directed toward restoration of the labrum rather than debridement or excision whenever possible.
Femoroacetabular impingement (FAI) is abnormal contact between the anterior femoral head and the acetabular rim, which impairs movement. FAI is more common among athletes. Mild symptoms of groin pain may occur variably for a long time before abruptly worsening. Symptoms are felt most noticeably after sitting with hips flexed to 90 degrees for a relatively long period and then rising to standing position. Range of motion testing often reveals diminished internal rotation with the hips flexed 90 degrees with near normal external rotation. MRI can be used to identify abnormalities. Treatment for FAI can include steroid injections to reduce inflammation, NSAIDs for pain, and physical therapy to improve mobility. Rest is also very important. If conservative measures fails, patients may be candidates for arthroscopic hip surgery.
Greater trochanteric pain syndrome is caused by tendinopathy of the gluteus medius or minimus. It is the most common cause of pain on the outside part of the hip (lateral hip). Pain is usually localized to the greater trochanter at the proximal end of the femur. Pain is triggered by resisting active abduction or standing only on the affected leg. Ultrasound may show thickening of the iliotibial band or tendinosis of the gluteal muscles. Treatment for greater trochanteric pain syndrome is mainly conservative including physical therapy, rest, NSAIDs, or steroid injections. Regenerative medicine, including stem cells and Platelet Rich Plasma (PRP) can also be an effective treatment. In refractory cases, surgical intervention such as bursectomy or tendon repair may be indicated.7
Sacroiliac joint dysfunction is a term to describe pain in the region of the sacroiliac joint believed to be due to malalignment or abnormal joint movement. There is no gold standard diagnosing procedure. Tests for pelvic symmetry or sacroiliac joint movement have been shown to have low tester reliability, and provocative maneuvers such as fluoroscopically guided injections of the sacroiliac joint can be useful for confirming the diagnosis. The most common symptom for sacroiliac joint dysfunction is lower back pain and pain in the buttock, but the sacroiliac joint may be a referred site of pain from degenerative disc at L5-S1, spinal stenosis, or osteoarthritis of the hip. Though conservative treatment is usually used to treat sacroiliac joint dysfunction, a new and minimally invasive procedure has been developed to treat sacroiliac joint disruptions. The LinQ procedure is an advanced procedure in which a LinQ implant is wedged into the joint to distract the sacrum and ilium relieving the source of the pain while, also providing mechanical stabilization of the SI joint. Demineralized bone matrix is also added to the LinQ implant to accelerate bond growth through the implant which will lock it into place and further stabilize the joint.
Hip pain is very common among athletes and elderly adults. There are many causes of hip pain. The pain specialists at The Denver Spine and Pain Institute are well trained to treat these exact conditions including injections, Regenerative Medicine (stem cells and PRP), MILD procedure, Veriflex, and the LinQ procedure, as well as a team of physical therapists to help bolster the strength of the hip. If you are suffering from hip pain, reach out to The Denver Spine and Pain Institute today to for a consultation and get back to a pain-free lifestyle.
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