Return to Play
Patients with chronic hip overuse injuries are often frustrated by the lack of progress and delayed return to play. These individuals must be educated from the first day that a prolonged recovery is usual.
Complete painless ROM needs to return before the patient should start significant strengthening exercises. After strengthening is commenced, endurance needs to be attained again. At this point, eccentric and plyometric exercises are started, and eventually, sport-specific drills that include cutting and cross-overs can begin. At any point if significant pain or stiffness returns, the athlete's progress needs to be slowed down and a step backward taken. Team athletic trainers or physical therapists can provide supervision and education to the athlete.
Complications
Other than worsening or returning pain, few complications of the overuse injury exist. Educating the athletes will remind them of the long-term nature of these injuries. As we age, our tendons age and degenerate, making recovery from these injuries more difficult.
If the patient's injury is not responding to treatment as quickly as expected, the physician should reconsider the diagnosis (see Differentials and Other Problems to Be Considered). Of paramount importance is reconsidering whether intra-abdominal, intrapelvic, or spinal pathology is responsible for the patient’s symptoms. Further imaging may be necessary to help rule out more worrisome diagnoses.
Prevention
Downplay the role of stretching, particularly in rapidly growing adolescents or mature weekend warriors because each, in their own way, needs short periods of light cardiovascular workouts, followed by several minutes of stretching of the lumbar, hip, and knee areas.
Most hip overuse syndromes occur not at the beginning of the athletic event, but after considerable time; this mechanism suggests a repetitive-use etiology or eventual microtears that are associated with aging and stiffened tendinous structures. Therefore, ask most patients to continue their warm-up and stretching programs, but athletes should not assume that warm-up and stretching programs, in themselves, are effective. Instead, these patients should attempt to exercise under the threshold that results in repetitive microtears and persistent hip pain. Athletes are well advised to develop programs of cross-training to maintain hip strength and flexibility if the slightest amount of hip tendinitis pain occurs.
Prognosis
Adolescents who present with pain around the hip joint by traction apophysis are expected to recover within a matter of months. Recurrence can be avoided if the intensity and volume of the sports activity is limited modestly until skeletal maturity occurs.
Aggressive athletes in their 20s or 30s may need ongoing physical therapy so that they can ascend the ladder of progressive exercise and return to their sports. Recurrence in this group is high, given the innate desire of these individuals to return to play too quickly. Fortunately, the tendinous structures in this group are pliable, and the chance for repetitive microtearing is lower than that in an older group.
Active athletes older than 40 years have the added burden of a decreasing tendinous pliability and a lower threshold of tendinitis recurrence. Their return to sports must be calculated with great care to slowly ramp up the level and intensity of their activity. A good rule of thumb is to not increase activity more than 10% per week until the patient has progressed back to reasonable exercise levels. In this active group, the reality of abandoning long-distance running or jumping sports may need to be addressed. The treatment team is encouraged to promote the patient's participation in new activities that provoke less hip pain, such as cycling.
