Hip Tendonitis and Bursitis

Rectus Femoris/Quadriceps

The rectus femoris originates at the ASIS (direct head) and AIIS (nondirect head) and crosses the hip and knee joint, making it the only quadriceps muscle to do so. It functions as a hip flexor and knee extender, and it receives innervation from the femoral nerve (L2-L4).

Strains of the rectus, which usually occur in the middle third of the thigh, may result in complete ruptures of the muscle belly, presenting as an acute enlargement of the affected thigh or a pseudotumorous growth. These deformities are out of proportion to their significance, however, because even complete ruptures of the rectus femoris result in little or no functional disability. The site of the strain is often tender to palpation and may be ecchymotic. An obvious defect can be palpated at times.

Chronic proximal rectus femoris or quadriceps pain can occur with apophysitis in the skeletally immature patient. Continued activity will weaken the growth plate, putting this area at risk for an avulsion after an acute stress of the muscle-tendon unit. This injury is accompanied by a pop or snap, with immediate pain and disability.

Iliopsoas Bursitis/Tendinitis

The iliopsoas is the primary hip flexor, and it is also an external hip rotator.[6, 14, 15]  This muscle is a combination of the psoas major muscle (originating at the lateral surface of the T12-L4 vertebral bodies) and the iliacus muscle (iliac fossa origin) below the inguinal ligament which insert on the lesser trochanter of the femur. The iliopsoas muscle receives its innervations from the femoral nerve and lumbar plexus (L1-L3). The trochanteric bursa lies beneath the muscle and is the largest synovial bursa in humans. This bursa can be from 5-7 cm x 2-4 cm in size and can communicate directly with the hip joint. Pain from the bursa or tendon is usually caused by an overuse injury, acute trauma, or rheumatoid arthritis.

The mechanism of injury for an acute iliopsoas trauma is usually a sudden hyperextension, which is commonly seen in athletes who are involved in rowing, uphill running, track and field, and strength training. This type of injury is usually seen in young adults and is more common in women. Patients present with pain over the anterior thigh with a palpable and/or audible snap. A shortened stride on the affected side may be present, and this is usually due to guarding against hyperextension of the hip.

Chronic anterior hip pain may result from iliopsoas or rectus femoris tendinitis. An audible or palpable snap may be felt with flexion or extension of the hip. As in all tendinitis and tendinosis, this is a result of repetitious weight-bearing activities, such as running and jumping. These conditions will often occur after abrupt changes in levels of activity, such as during preseason training or when an individual is first training for a race. Because tendinosis is a degenerative process, less obvious changes in activity can lead to symptoms in older patients and will have a more insidious onset.

The symptoms of pain and tightness will initially start after an activity but will progress to occur during the workout over time. Eventually, the individuals will stop the workouts because of the pain, and their activities of daily living may be affected.

The patient will complain of anterior hip and groin pain that is worsened with extension of the hip or active flexion of the hip or active extension of the knee against resistance. Getting out of a car or walking up the steps will lead to increased pain.

A palpable mass may also be noted under the inguinal ligament, at which time a consideration of aspiration or a steroid injection may be considered if ultrasound guidance is available.

Gluteus Medius Syndrome and Trochanteric Bursitis

The gluteus medius functions as a primary hip abductor.[1, 8, 16, 17]  It originates at the external surface of the ilium and inserts onto the posterior lateral surface of the greater trochanter. This muscle is innervated by the superior gluteal nerve (L4-S1).

The greater trochanteric bursa lies directly lateral to the greater trochanter. This lateral growth of the femur abuts the tensor fasciae latae and lateral quadriceps muscles. The bursa provides lubrication and cushioning to allow the muscles to flex and extend over the trochanter without damaging the muscles. It also cushions the tendon before the attachment of the gluteus medius and minimus. Bursitis in this area can be secondary to changes in activity or training, biomechanical problems lower down the leg, or from direct trauma. These conditions lead to increased pressure of the muscles against the bursa and trochanter—with resultant inflammation.

Pain will occur with hip flexion such as walking, climbing stairs, or getting out of a car or a chair. Nocturnal pain while lying on the affected side is common. A snap is occasionally felt or heard in the lateral hip with flexion or extension.

Gluteus medius syndrome involves tenderness to palpation of the gluteus medius muscle, which can be triggered by sudden falls, prolonged weight bearing on one extremity for long periods, activity overuse, or sporting injuries. Most commonly, this situation is observed in middle-aged women who have embarked upon a vigorous walking program or who have started working out at a health club. Patients may present with pain that is transient and worsening over a time period, a Trendelenburg gait, and weakness. These symptoms specifically affect runners, as there is tilting of the pelvis with running. It is important for the clinician to examine the patient for a leg-length discrepancy.

Hip-abduction strengthening should be avoided in the initial stages of gluteus medius syndrome because it only provokes tendinitis. As the acute stage resolves, hip-abductor strengthening is important and is best achieved in the aquatic environment.

It can be difficult to distinguish between trochanteric bursitis and gluteus medius tendinitis due to their proximity at the insertion site. Resistance to abduction or internal rotation of the hip may help distinguish these 2 entities, as trochanteric bursitis will not elicit pain with resisted hip abduction, and gluteus medius tendinitis will present with more posterior tenderness to palpation at the insertion site. Diagnostic ultrasound can be performed to determine if fluid is present in the bursa or to look for echogenic changes that are consistent with tendinopathy. Ultrasound-guided injections into the greater trochanteric bursa will be more effective if fluid and distention of the bursa can be demonstrated.[18, 19]

Long et al conducted a study to test the hypothesis that sonographic evaluation of sources for greater trochanteric pain syndrome would show that bursitis was not the most commonly encountered abnormality.[20]  The study population consisted of 877 unique patients: 602 women, 275 men; average age, 54 years; and age range, 15-87 years. Of the 877 patients with greater trochanteric pain, 700 (79.8%) did not have bursitis on ultrasound. A minority of patients (177, 20.2%) had trochanteric bursitis. Of the 877 patients with greater trochanteric pain, 438 (49.9%) had gluteal tendinosis, four (0.5%) had gluteal tendon tears, and 250 (28.5%) had a thickened iliotibial band. The authors concluded that the cause of greater trochanteric pain syndrome is usually some combination of pathology involving the gluteus medius and gluteus minimus tendons as well as the iliotibial band. Bursitis is present in only the minority of patients. These findings have implications for treatment of this common condition.[20]

An MRI study suggested that there is an association between increased acetabular anteversion and gluteal tendinopathy, which supports a growing body of evidence implicating abnormal biomechanics in the development of this condition.[21]

Groin/Adductor Strain

Adduction of the hip is performed by the gracilis, pectineus, obturator externus, adductor longus, adductor brevis, and adductor magnus muscles. The main origin is along the pubic ramus, and the insertions range from the trochanteric fossa to the tibial tuberosity. The obturator nerve (L2-L4) provides the main innervations for the adductor muscle group.

Adductor or groin strains are commonly seen in ice hockey and soccer players.[9]  These injuries are usually the result of strong eccentric contractions and rapid decelerations that occur during these sports activities, and they are often accompanied by a pop, with immediate resultant pain and disability. Often, weight bearing will be difficult, and the athlete may need to use crutches. The adductor longus is most commonly injured, and athletes classically present with pain with the following: (1) palpation of the muscle belly and insertion, (2) passive stretching, and (3) resistance to contraction.

Adductor strains are also common in football, figure skating, and track and field. Athletes at risk are those with decreased adductor strength, lack of off-season conditioning, inadequate warm-up and stretching, and a history of previous strains. Adductor strains are graded from first degree to third degree, ranging from a minimal loss of strength and ROM (first degree) to a complete loss of muscle function (third degree). If these injuries are not properly rehabilitated after the acute stage, they may become chronic, leading to a more frustrating situation for the athlete.

Hamstring

The hamstrings function as hip extensors and consist of the semitendinosus muscle, semimembranosus muscle, and the biceps femoris. These muscles originate from the ischial tuberosity, with the short head of the biceps femoris coming off the middle third of the femur. They insert onto the medial tibia (semimembranosus and semitendinosus) and lateral fibula (biceps femoris).[22, 23]

Acute hamstring injuries occur with the acceleration associated with sprinting and court or field sports. A snap or pop is felt, and immediate pain will limit further participation. Risk factors for these injuries are similar to other acute injuries mentioned above, such as poor warm-ups, poor flexibility, or decreased strength from previous hamstring strains. Acute hamstring injuries most often occur within the mid belly of the muscle, but myotendinous rupture can occur.

Chronic hamstring pain can result from a poorly rehabilitated acute injury in which the strength was not completely restored. Proximal hamstring tendinitis is less common than chronic muscle-based pain. Apophysitis and acute avulsions from the ischial tuberosity occur in skeletally immature athletes, such as gymnasts and dancers.

United States statistics

Hip overuse syndrome is a relatively common condition, particularly in people who are physically active.

Snapping hip syndrome is the third most common hip pathology in young women and is most frequently observed among gymnasts and ballet dancers. The syndrome has been reported as an incidental finding in approximately 5-10% of the general population.[24]

International statistics

Among soccer players, 10-18% of all injuries are hip or groin injuries, and 62% of these are adductor strains.[9]

An Australian study showed that hamstring injury accounts for 10% of all injuries in field-based team sports (soccer, rugby union, field hockey, Gaelic football, hurling, and Australian football).[25]

The hip joint can be imagined as a ball and socket. The ball, called the femoral head, is seated within the acetabulum of the pelvic bone (the socket). Both of these bones are covered by articular cartilage, a lubricating and cushioning layer that helps to prevent damage to the underlying bones. Likewise, the labrum is a cushion of fibrocartilage deep within the socket that helps to aid articulation and provide further cushioning.

The hip joint is subject to strong forces (which can be multiple times the body weight) with all weight-bearing activities, from walking to running, as well as jumping and cutting sports. This is due to the long, lever-arm mechanism of the lower extremity, with the hip joint being the fulcrum. Thus, the hip joint is often the location of degenerative arthritis as people age.

The capsular ligaments of the hip joint, which act like ropes, are formed from thickened portions of the joint capsule, helping to keep the 2 bones together and aid in articulation. These ligaments provide stability and tension to the joint with movement.

Anteriorly, the rectus femoris, iliopsoas, gracilis, and sartorius muscles connect the pelvic bone to the femur and help aid in flexion of the femur, bringing the leg up toward the body. These muscles, along with the rest of the quadriceps muscles, which extend the knee, are the largest and most powerful muscles in the body, responsible for producing large concentric, isometric, and eccentric forces. Because of this, these muscles are subject to traumatic injuries and tears from sudden starts (concentric contraction), stops (eccentric contractions), and direct trauma, as well as overuse injuries from repetitive activities (microtrauma).

Medially, the set of 3 adductor muscles and the pectineus connect the inner aspect of the femur to the front and inferior aspect of the pelvis; contracting these muscles adducts the femur back to midline and across the body (ie, crossing the legs). From the outside, the tensor fasciae latae and biceps femoris (toward the back) aid in abduction, moving the legs outward from the body. Posteriorly, the semitendinous and semimembranous muscles (the hamstrings), the biceps femoris, and the large gluteus maximus extend the leg backward from the body.

The gluteus medius, another posterior muscle of the hip and buttocks, aids in internal rotation and abduction of the thigh. The piriformis, quadratus, and superior and inferior gemelli work in tandem to perform external rotation of the hip.

All of the previously mentioned muscle groups are subject to increased loads in athletic and recreational activity (see Functional Anatomy). Tendons, which attach muscle directly into bone, are structures that are subject to high tensile strength, meaning they must stretch as the muscles shortens, but they do not provide strength. Inflammation of a tendon from injury or repetitive stress is called tendinitis.

Several tendons are cushioned from the underlying bone by a lubricating and cushioning sac called a bursa. The largest bursa in the hip joint is between the iliopsoas muscle and the pelvic brim and is called the iliopsoas bursa. Between the tensor fasciae latae and gluteus medius muscles and the greater trochanter of the femur, a portion of bone that juts out laterally from the proximal femur, lies the greater trochanteric bursa. Any bursa within the body can be inflamed from repetitive stress of the overlying muscles, direct trauma, or a spreading infection.

The tendinous portion of the muscle has poor blood flow, so injury or stress at the attachment of the tendon onto the bone can lead to degeneration of the area. This degeneration is associated with the disorientation of collagen fibers, increased cellularity, and angiofibroblastic degeneration. Pathology examination of these tendons fails to reveal inflammatory cells or increased blood supply to the area. These "scars" within the tendon are difficult to treat because of decreased blood flow into the injured area.

In the pelvic bones of children, adolescents, and young adults, the tendons attach onto a secondary growing portion of bone. This connection between the larger pelvic bone and smaller secondary growth area is called the apophysis, and in this age group it is the weakest link from the musculature to the bone. Consequently, the apophysis can be the direct source of pain from irritation (apophysitis), or it can be broken apart by a strong force on the tendon and pulled away from the larger pelvic bone (avulsion fracture).

Avulsion fractures around the pelvis occur in prepubertal athletes as the result of an actively contracting muscle encountering abrupt resistance such as a misstep, rapid acceleration, or eccentric movements. The treatment of most smaller avulsion fractures is similar to the treatment of strains of the muscle-tendon unit.

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.

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). 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.

Taking an appropriate history from a patient with hip pain is of paramount importance. The first focus should be on the patient’s account of the pain. If the pain was of an acute onset after an injury, the incident should be thoroughly described. Was there a snap or pop? Did it occur during acute acceleration or deceleration? What was the exact motion occurring during the injury (ie, foot planter, how was he/she hit, etc)? Was the athlete able to bear weight after the injury? Could he or she continue playing? These injuries often occur with a pop or snap, with a resultant sudden, severe, well-localized pain and immediate disability.

If the pain has been more long term, a review of the athlete's training methods, distances, and activity level should be explored. Does the pain start during the activity, or only afterward? Is there night pain? Is the pain better the next day or worse? Is the pain occurring earlier in the activity? Do any specific activities or movements increase the pain?

Ask the patient about a previous history of similar problems. Has there been any previous diagnostic testing or treatment?

To rule out more dangerous pathologies, always ask about night sweats, fevers, weight loss, or anorexia. Is there any history of stress fractures, menstrual irregularities, or amenorrhea?

To rule out abdominal sources of the hip pain, ask about nausea, vomiting, diarrhea, changes in stools, or the presence of blood in stools.

To help rule out spinal causes, ask about lower back pain; radiation of pain down the leg into the calf, foot, or toes; and numbness, tingling, or weakness in the leg or foot.

It is important to do a thorough examination of the hip in order to establish any limitations or deficits that the patient may have. Along with a hip examination, an examination of the knee and lumbosacral spine is important to establish if the patient's hip pain is referred pain from these sites. A systematic approach of observation, palpation, checking range of motion (ROM), and strength testing is important.

Observation

Observe the patient from the front, back, and sides. Note any asymmetry, as well as how the patient’s clothing rests on the waist and hips. Then, observe the patient walking to see if one side is favored over the other. These observations can be helpful clues in focusing the examination, as well as in detecting signs of a leg-length discrepancy. Swelling and ecchymosis can be present with more severe strains, but these findings are often absent because the injured structures are deep in the hip.

Palpation

Along with bony palpation (see below), it is important to appreciate the patient's muscle tone as this may be an indicator of muscle strain or guarding against underlying pathology. Acute or chronic injuries lead to tenderness of the muscle and tendon. Spasm after an acute injury is common. Passive stretching and active contraction of the muscle is often difficult but can help to pinpoint the exact anatomic injury.

It is important to establish and palpate the following landmarks:

• Boney landmarks

  • Anterior superior iliac spine (ASIS) – Sartorius and tensor fasciae latae

  • Iliac crest – Gluteal muscle attachment

  • Anterior inferior iliac spine (AIIS) – Rectus femoris attachment

  • Greater trochanter – Vastus lateralis and gluteal muscles

  • Posterior superior iliac spine (PSIS)

  • Ischial tuberosity – Hamstring muscles

  • Pubic ramus – Adductors

• Muscle landmarks

  • Anterior – Quadriceps muscles

  • Posterior – Gluteal muscles and hamstring muscles

  • Medial – Adductor muscles

  • Lateral – Iliotibial band and gluteal muscles

ROM

It is important to check both active and passive ROM of the hip to assess and establish limitations and barriers. Actual measurements will help to the clinician to monitor the patient’s progress over time.

• Rotation

  • Hip rotation is evaluated by having the patient seated with the knee flexed at 90° and moving the foot from the midline. Internal foot movement equates to external hip rotation (60°) and external foot movement results in internal hip rotation (30°).

  • Another way of measuring hip rotation is to have the patient lying on his or her back. Flex the hip 90º and internally and externally rotate the hip. Limitations of internal rotation occur most often with hip osteoarthritis, femoral head osteonecrosis, and stress fractures of the femoral neck.

• Flexion/Extension

  • Hip flexion (120°) is assessed with the knee flexed, and hip extension (15°) is examined with the patient lying in the prone position with the leg kept straight and elevated.

• Abduction/Adduction

  • Abduction (45-50°) and adduction (20-30°) are performed with the patient lying supine and using the ankle to move away (abduction) or toward the midline (adduction). Follow the ROM examination with strength testing, which is performed by applying resistance to the ROM discussed above.

  • Pain and resistance to quadriceps stretching indicates injury at the proximal rectus femoris, such as a myotendinous strain or avulsion. An injury at the origin of the hamstrings will cause similar findings with a seated or lying straight-leg raise.

• Sensory

  • The sciatic (motor and sensory) and the lateral femoral cutaneous (sensory) nerves are commonly responsible for pain or numbness around the hip. Sciatic nerve pain and numbness can occur in the posterior hip and thigh with or without radiation. The lateral femoral cutaneous nerve provides sensory enervation to the anterolateral thigh and can be compressed as it passes under the inguinal ligament, especially in obese individuals, leading to a condition known as paresthetica meralgia.

Special Tests

Leg-length testing: With the patient supine, take linear measurements from the ASIS to the medial malleolus on each extremity. Then, have the patient flex his or her knees, and observe if one knee is higher (longer tibia) or if it is more prominent (longer femur).

Trendelenburg test: Have the patient stand on one foot; the examiner then observes for a pelvic tilt toward the side of the raised foot. This is an indication of weak abductors on the opposite hip.

 A study by Allison et al found that patients with gluteal tendinopathy use different frontal plane kinematics of the hip and pelvis during single leg loading.[26]

Thomas test: With the patient supine, the examiner places one hand under the patient's lumbar spine, and the patient flexes one hip toward the body. When the spine touches the examiner's hand, the pelvis is stabilized and further flexion now occurs solely from the hip. Flexion of the contralateral leg during further flexion of the ipsilateral hip or arching the back during extension may be a sign of a flexion contracture.

Hop Test: Pain in the ipsilateral groin region when the patient hops on one leg may be a sign of a femoral neck stress fracture.

FABER (flexion, abduction, external rotation) or Patrick test: This test is frequently used to differentiate lumbar spinal problems from primary hip pathology. This comprehensive maneuver elicits anterior hip or groin pain. If there is significant loss of ROM from a mechanical means (ie, not pain-inhibited), consider an intra-articular problem, such as hip arthritis or avascular necrosis. If groin pain is elicited and yet the range of motion is relatively normal, suspect iliopsoas tendinitis. If the FABER/Patrick test produces posterior hip pain, consider a disorder of the sacroiliac (SI) joint. To perform this test, the patient's affected hip is moved into flexion, abduction, and external rotation while he or she lies supine with one ankle placed over the opposite knee ("figure 4" position). If pain is elicited when the examiner presses down on the flexed knee, this test may indicate an SI joint pathology or adductor muscle and tendon pain.

Ober test: With the patient lying on the unaffected side, passively abduct the upper leg and flex the knee to 90º. Slightly extend the hip, and observe if the hip drops into the adducted position. Decreased adduction is a sign of tightness in the tensor fasciae latae and/or the iliotibial band.

The cause of many overuse injuries of the hip can be traced to biomechanical problems farther down the kinetic chain. One should exam the knees to determine valgus or varus alignment. The alignment of the hindfoot, pronation of the ankle, and cavus or planus foot type should be determined.

Laboratory tests are usually not indicated for most patients with acute or chronic hip pain. Patients with constitutional symptoms such as prolonged fever, night sweats, or weight loss, or who have a history of juvenile or rheumatoid arthritis should have a complete blood cell (CBC) count, complete metabolic panel, and perhaps an erythrocyte sedimentation rate (ESR) performed.

Radiography

Plain radiographs are indicated for injuries that result in immediate, significant disability. These x-rays will help the clinician to determine if a fracture or avulsion fracture is the cause of the disability. Hip joint osteoarthritis, avascular necrosis, and femoral neck stress fractures can also be diagnosed.

A 2-view radiograph, anteroposterior (AP) and lateral view of the hip, will adequately depict most clinically significant avulsion fractures. The frog-leg view is most useful for determining the presence of a stress fracture to the femoral neck. Stress fractures may be present if localized periosteal bone formation is noted in the femoral shaft or cortical breaks in the superior femoral neck. Avulsion fragments greater than 2 cm are usually an indication for surgical referrals for possible screw placement.

Magnetic resonance imaging (MRI)

MRI studies are increasingly used to help aid in the diagnosis of acute and chronic hip pain.[27, 28] MRIs show good definition for large muscle and tendon tears and aid in providing prognostic information based on the presence of edema, blood, or large fluid collections. In addition, the presence of large areas of tendon inflammation and degeneration can often be noted. MRI also determines whether collections of fluid are present in a bursa, although greater trochanteric bursitis is often not seen on MRI. Iliopsoas bursal collections can be visualized because they tend to be larger. Stress injuries of the apophysis and stress fractures of the pelvis, femoral neck or shaft, and pelvic bones are easily visualized on MRI. Degenerative changes within the hip joint and avascular necrosis are also evident on noncontrast MRIs. Of course, neoplastic processes are best evaluated with contrast-enhanced MRI. Intra-articular labral tears can only be diagnosed with a magnetic resonance arthrogram of the hip joint. The contrast must be injected into the joint under direct fluoroscopic or ultrasound guidance, which makes this imaging test more difficult to perform. Limitations of MRI include excessive cost, increased time to obtain images, and the static nature of the test.

A study by Grimaldi that involved 65 patients with lateral hip pain reported that the probability of gluteal tendinopathy presence on MRI moves from 50% to 98% if pain is reported within 30 seconds of standing on the affected limb.[29]

Bone scanning

Radionuclide triple-phase bone scans are indicated for the diagnosis of stress fractures anywhere in the body. These studies will typically show increased bone activity within 3 days of the commencement of the athlete's symptoms and are rarely falsely negative.

Diagnostic ultrasound

Diagnostic ultrasound is increasingly used in the sports medicine office.[30] Ultrasound machines may be mounted on carts or are portable, and they usually contain a 6–12 mm probe, which provides for adequate visualization for most musculoskeletal complaints. Ultrasound is useful in visualizing the fluid collections that are present with iliopsoas or greater trochanteric bursitis, as well as for demonstrating hematomas from acute quadriceps strains. Tendons can easily be seen, and partial or complete tendon ruptures and avulsions can be determined.

Tendinopathy is also easily visualized with ultrasound. The ultrasound criteria for tendinopathy include enlargement of the tendon, hypoechoic and hyperechoic changes that demonstrate collagen disorganization, microcalcifications, minute tendon tears, and decreased flow within the tendon. The iliopsoas, gluteus medius, proximal hamstring, and rectus femoris tendons are all easily visualized. Dynamic ultrasound is extremely useful for the evaluation of a snapping hip to determine the exact tendon involved, such as the iliopsoas snapping over the pelvic ring, or the tensor fasciae latae snapping over the greater trochanter. Ultrasound can also be used to guide injections into fluid collections, bursae, and the hip joint, and for guiding needle-based interventions for chronic tendinopathy.

Fearon et al evaluated the positive predictive value of preoperative ultrasound assessment in 24 patients with greater trochanteric pain syndrome refractory to nonoperative therapy who underwent combined gluteal tendon reconstruction and bursectomy.[31] The investigators compared the preoperative ultrasound images with surgical findings and found a high positive predictive value for gluteal tendon tears.

Rehabilitation Program

Physical Therapy

The initial treatment for all chronic hip overuse injuries is similar, and this can be taught to patients in the office or via formal physical therapy. The initial alleviation of overuse pain is accomplished with relative rest of the painful area. The patient may continue to work out other body parts and attempt to maintain cardiovascular fitness. Pain relief can be improved with oral anti-inflammatory medications, as well as with modalities such as ice, ultrasound treatment, and high-intensity galvanic stimulation. Patients thought to have tendinopathy can use acetaminophen for pain relief because the affected tendon is not inflamed.

To prevent further symptoms, increasing the length of the muscle-tendon unit with stretching and increasing joint flexibility are paramount.[32] Active stretching of the injured muscle must be accomplished to improve its length. At the same time, the injured muscle must be strengthened. Eccentric exercises, in which the muscle is lengthened and tightened at the same time (such as with lunges) should be added once full lengthening has returned. Once the proper length of the muscle has been attained and its strength restored, the addition of activity and sport-specific exercises completes the rehabilitation. Increasing the flexibility and strength of the opposing muscle groups is also required.

Because most of these muscles attach to the pelvic ring, attention to stretching and strengthening of all peripelvic tissues is helpful. Increasing the strength of the abductor muscles, such as the gluteus medius, should improve pelvic stability. Manual therapies are also helpful for manipulating the symphysis pubis and SI joints.

Leg-length discrepancies greater than 1 cm should be corrected with shoe lifts to improve balance and pelvic symmetry. Likewise, correction of any pes planus and the use of anti-pronation devices with an over-the-counter or custom orthosis is imperative for active individuals who do weight-bearing exercises or who run and walk regularly.

Medical Issues/Complications

If the patient's condition is not responding as expected to treatment for the initial diagnosis, a second look at the symptoms and perhaps an additional piece of imaging may be performed to confirm that the diagnosis was appropriate (see Differentials).

Intra-abdominal or pelvic pathology can occasionally cause hip pain. If any gastrointestinal symptoms such as a change in bowel habits; the presence of blood in stool; or the presence of gynecologic symptoms such as bloating, new menstrual irregularities, or dyspareunia are present, a gastrointestinal or genitourinary workup may be necessary.

Surgical Intervention

Surgical therapy for chronic hip overuse injuries is occasionally necessary. Partial tendon excision and debridement of tendon scars have been performed for both adductor and hamstring injuries that fail to resolve. These surgeries are usually reserved for high-level athletes whose conditions fail to improve and who return to activity with prolonged courses of physical therapy. After surgery, such a prolonged physical therapy is needed to return athletes to their full ROM and strength.

Large avulsion fractures of the rectus, hamstring, and iliopsoas should be internally fixated. Likewise, large apophyseal avulsions (greater than 2 cm) should be repaired. Intra-articular disorders, such as labral tears, and intra-articular loose bodies need hip arthroscopy to improve an individual's symptoms and level of activity.

Other Treatment

Low-energy extracorporeal shock wave (ECSW) therapy may be a consideration in the treatment of greater trochanteric pain syndrome. In a study by Furia et al, affected patients either received the ECSW therapy (n = 33) (2000 shocks; 4 bars of pressure, equal to 0.18 mJ/mm(2); total energy flux density, 360 mJ/mm2) or additional conservative therapy (n = 33).[33] Both patient groups had equivalent pretreatment visual analog scores. However, at 1, 3, and 12 months post treatment, the group that received ECSW had greater visual analog and Harris hip scores than the group receiving conservative therapy, and at final follow-up at 12 months, the Roles and Maudsley scores (ie, successful results) were significantly greater in the ECSW group relative to the control group.[33]

Rehabilitation Program

Physical Therapy

See Treatment, Acute Phase.

Tendinopathy treatment can often be frustrating for clinicians and patients alike. The degenerative tendon must be lengthened with aggressive and constant stretching. Eccentric exercises have been proven to decrease pain and return patients to a full level of activity in both hamstring and patellar tendinopathy.

Consultations

The treatment of hip overuse syndrome (traction tendinitis) is never a short-term proposition; thus, treating this condition effectively requires a team approach. Optimally, medical resources are available to include a physical therapist and a fitness trainer who are skilled in laddered, progressive exercise following an individual's injury.

Chronic hip pain often goes undiagnosed, leading to psychologic difficulties from the debilitating nature of the pain itself and the frustration of being unable to return to a sport or exercise in a timely fashion. A psychology consultation may be indicated in such cases.

Other Treatment (Injection, manipulation, etc.)

The treatment of greater trochanteric bursitis involves lengthening the tensor fasciae latae/iliotibial band complex.[34] Additionally, an injection of corticosteroid into the affected bursa can be added if necessary.[35] Likewise, injections into the iliopsoas bursa can be performed by experienced clinicians using ultrasound guidance.

Interventional treatments for chronic tendinopathy have met with varied success. The goal of all of these therapies is to restart the healing process by increasing inflammation and blood flow into an area, thereby allowing new progenitor cells to come into the area, lay down healthier collagen, and improve the organization of collagen. Any patients who undergo these treatments should not use anti-inflammatory medications because these drugs will prevent the inflammation that is being sought.

Prolotherapy (also called proliferative therapy) involves injecting 3% NaCl or 10% dextrose into and around the affected tendon to restart the inflammatory cascade.

Injections of autologous whole blood and platelet-rich plasma concentrations have also been attempted for the treatment of tendinopathy in other parts of the body.[36] Using these injections under ultrasound guidance will likely increase their effectiveness. Likewise, performing percutaneous needling of the tendon by fenestration with an 18- or 21-gauge needle before administration of the injection will improve the flow of blood and inflammation into the tendon.

A randomized, double-blind controlled trial by Fitzpatrick et al that included 80 patients with gluteal tendinopathy reported that patients treated with a single platelet-rich plasma injection achieved greater clinical improvement at 12 weeks compared to those treated with a corticosteroid injection.[37]

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.

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.

For patients with hip overuse syndrome, medications are used primarily to decrease pain and inflammation. These agents are best used for short time periods in the acute setting after an injury to prevent further swelling and pain.

Inflammation is part of the normal healing response and may be necessary to allow for complete tissue recovery. Some theories regarding tendinopathy involve the belief that stopping the healing response by halting all inflammation prevents the eventual recovery of tendons by interfering with normal collagen deposition and alignment. By preventing new blood-vessel formation into an injured area, complete healing does not occur.

In patients without known contraindications, nonsteroidal anti-inflammatory medications (NSAIDs) are preferred for short time periods for pain and inflammation control. Providers can decide which NSAIDs are the ones they are most comfortable using.

Class Summary

NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well; these may include inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

Ibuprofen (Motrin, Excedrin IB, Ibuprin, Advil)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Naproxen (Naprosyn, Anaprox, Aleve, Naprelan)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.

Ketoprofen (Actron, Orudis, Oruvail)

For relief of mild to moderate pain and inflammation.

Small dosages initially indicated in small and elderly patients and in those with renal or liver disease. Doses over 75 mg do not increase the therapeutic effects. Administer high doses with caution and closely observe patient for response.

Nabumetone (Relafen)

Nonacidic NSAID that is rapidly metabolized after absorption to a major active metabolite that inhibits cyclooxygenase enzyme, which in turn inhibits inflammation.

Class Summary

COX-2 inhibitors are a class of NSAIDs that have a decreased incidence of adverse GI effects, such as gastritis and ulcers. COX-2 inhibitors may be indicated in patients with a history of gastric ulcers, who require anti-inflammatory medications.

Celecoxib (Celebrex)

Inhibits primarily COX-2, an isoenzyme that is induced during pain and with inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, the COX-1 isoenzyme not inhibited; therefore, GI toxicity may be decreased. Seek the lowest dose for each patient.

Class Summary

Simple analgesics like acetaminophen may be preferred for conditions in which NSAID use is not advised or in which there is little suspicion of an underlying inflammatory process.

Tramadol hydrochloride is an opioid analgesic that has noradrenergic and serotonergic properties that may contribute to its analgesic activity. Tramadol is used for moderate to severe pain or in cases wherein NSAIDs cannot be taken. The potency of this agent is less than that of traditional opioids, and there is less (but not zero) addiction potential.

Acetaminophen (Aspirin-free Anacin, Tylenol, Feverall, Tempra)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI disease, or those taking oral anticoagulants.

Tramadol (Ultram, Ultram ER)

Inhibits ascending pain pathways, altering perception of and response to pain. Also inhibits reuptake of norepinephrine and serotonin.