Acute Phase
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]
Recovery Phase
Rehabilitation Program
Physical Therapy
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]
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.
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.
