Causes and treatments of hip pain | Body maintenance and home treatments | Video: A Patient's Guide to Knee and Hip Replacement

What hurts? - Hip

Basic Anatomy

The hip is a ball and socket joint formed by the upper part of the femur (thigh bone) and the lower part of the pelvic bone. The upper femur is the ball portion of the joint and the pelvis forms the socket. Like other joints, there is much more to the hip than the bones of the ball and socket, there are ligaments, tendons, cartilage and other structures (such as the labrum) in and around the joint proper, all of which play a role in hip function.

Hip Function

The hip joint’s role is to permit motion of the thigh with respect to the pelvis. Unlike a hinge joint (like in your fingers), the ball and socket hip joint can permit motion in several different directions, plus permit rotation. This is unusual for joints. Activities such as putting one’s shoes on or pivoting all require some combination of hip bending and rotation. Naturally, walking and running require the hip to be strong enough to tolerate weight bearing. The structures operate together complexly without us thinking much about the fine coordination and intertwined function required for activities such as walking, skiing, and running.

Misleading Symptoms

Some symptoms that may seem like a hip problem may actually be a more severe back problem. Be sure to check out all persisting hip pain with a specialist. For instance, a tingling or numb sensation in the hip or upper thighs may actually be a symptom of spine damage. Also, when pain does not lessen when lying down or sitting in a way that relieves pressure, then the problem may be rooted in the back, not the hip. This type of pain should be treated immediately.

Causes of Hip Pain

Hip pain quick links:

• Strains and Sprains
• Bursitis
• Hip Arthritis
• Labrum
• Stress Fractures
• Hip Fractures

As you may imagine, hip pain can occur when one or more of these structures is injured, deformed, or deteriorating. Among the most common causes of hip pain are sprains, strains, bursitis, arthritis, torn tissues (such as a torn labrum), and stress fractures.

Strains and Sprains

Strains and sprains frequently cause hip pain and occur suddenly when the pressure on the hip tissue is too great for the tissue to withstand. This mechanism can cause immediate sharp pain around the hip, such as out to the side or near the buttock. Patients with hip pain often feel as though the pain is coming from the groin, oddly enough (the ball and socket joint of the hip is just deep to the soft tissues overlying the groin). The pain usually worsens when tension is applied to the tissue, such as moving the hip in a particular direction. Thankfully, the pain from sprains and strains usually resolves over a relatively short time span, usually 1 – 2 weeks. This pain is typically eased by rest, medicines such as Tylenol and / or ibuprofen, and sometimes other treatments such as ice, or gentle physical therapy. If the pain is taking longer than a few weeks to resolve, then the cause of the pain may not be a sprain or strain. The diagnosis can be made by visiting with one of our physicians.

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Bursitis

A bursa is a gelatinous, filmy structure located near some joints, such as the shoulder, knee, and hip. It is suggested that its function is to help protect or lubricated tendons near bony edges. The bursa near the hip is the trochanteric bursa, and is located near the bony knob on the outside of our hips. It can become inflamed because of modifications in how one walks, with over use, trauma, or sometimes for no clear reason at all. Patients with hip bursitis will often experience pain on or near that bony knob when pressure is applied to it and the pressure can occur with walking or other weight-bearing activities, or simply by lying on it.

The diagnosis of bursitis can be made by your orthopedic physician. This requires a visit to their office, where they will review your description of your symptoms and other relevant facts about your medical history. A physical examination usually follows, and in turn, may include x-rays. Once the diagnosis of bursitis has been made, treatment often follows. The good news is that bursitis usually goes away without surgery. The vast majority of cases improve with medicine, time, physical therapy, stretching, and occasionally a cortisone injection. If you are diagnosed with hip bursitis, you can help determine with your orthopedic physician which of these treatments is a good idea for you.

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Hip Arthritis

Hip arthritis is a condition associated with deterioration and loss of cartilage that normally coats the bony surfaces of the hip’s ball and socket. The actual cause of cartilage loss is complex and not fully understood. It’s most simply explained as a “wear and tear” phenomenon, but certainly other factors play a role, such as genetics, workload, history of prior injury, etc. Wear and tear, or osteoarthritis is the most common form, while less common types of arthritis include rheumatoid arthritis and psoriatic arthritis. Avascular necrosis is a rare condition in which the blood supply to the bone of the ball is disrupted, and the bone and cartilage crumble away, leading to an arthritis-like picture.

When the cartilage deteriorates, there are no more smooth surfaces to rub on each other during motion. The cushioning effect is also lost, which leads to the bone of the ball and socket rubbing on one another. While bone is well suited to weight bearing, it does not work well as a surface through which motion occurs. It’s analogous to the rim of a wheel being well-suited to the loads of a car provided it’s surfaced with a tire. Without the tire, the rim does not function well. At any rate, in the absence of cartilage, the joint undergoes a cascade of events including the release of chemicals and cells within the joint, disruption of normal joint fluid content, formation of bone spurs, development of cysts within the bones, and even the formation of loose bits of bone floating loose within the joint (loose bodies). These abnormalities are likely the causes of the pain associated with arthritis.

Arthritis pain is often described by our patients as a deep ache with occasional sharp components. Typically the pain localizes to the groin or buttock or outside part of the hip. The pain seems to start slowly, over a period of weeks to months, for example. It tends to worsen over time, bothering patients rarely during its early stages, but later, as the arthritis worsens, even light activities such as walking become painful, including those that were well-tolerated during the early stages of arthritis. Pain at night that disrupts sleep is not uncommon. Patients also describe having worse pain associated with more vigorous activities; that is, the more strenuous the activity, the more pain they seem to experience during and afterwards. As a result, people start to avoid activities such as vigorous outdoor sports (like running, hiking for example) because of the pain they generate.

Visiting one of our physicians can help determine whether a patient with hip pain has arthritis. The physician will typically listen to the patient’s description of their symptoms, ask some questions and review other information from the patient’s medical history. A non-invasive physical examination then usually follows. X-rays usually show significant abnormalities if arthritis exists, and can be obtained at the time of the evaluation. Other tests (such as MRI) are usually not required to detect arthritis, but may be considered in some circumstances.

Treatment

Treatment of hip arthritis usually starts with the use of relatively cheap and safe options, such as exercise and stretching that the patient can tolerate. Weight loss may be advised as well as can avoiding activities that worsen the pain. These treatments do not cost anything, and seem to have some benefit in the early phases of arthritis. As the arthritis worsens, however, these relatively easy treatments usually stop being effective, which leads the patient and physician both to consider other options such as medicines or other therapies. Medicines usually used to treat arthritis include acetaminophen (Tylenol) and ibuprofen and its cousins (non-steroidal anti-inflammatory drugs, or NSAIDS for short). NSAIDs besides ibuprofen include naproxyn sodium (Aleve) which is available without prescription over the counter, and other prescription medicines, such as Celebrex and Relafen, for example. These medicines can be taken before activities the patient knows to produce pain. They can also be taken when pain is troublesome. Other therapies which can be considered include physical therapy, cortisone injection, orthotics, massage therapy, acupuncture, herbalism, supplements, and other complimentary therapies. The success of these treatments, medicine, and other therapies is usually short-lived in our experience and, while the number of such options available to patients is great, the research supporting their use as a cure is weak. This should come as no surprise because none of them address the underlying cause of the arthritis; that is none of them re-grow the cartilage that has been worn away. That said, these treatments often help decrease the symptoms and so patients and physicians alike are attracted to them. Whether a particular treatment is right for you can be determined by discussing things with your orthopedic hip physician.

Surgical treatment for arthritis is considered when the patient has exhausted other options. The surgical options include primarily hip replacement or hip resurfacing. Usually hip arthroscopy (“Hip scope”) and other hip surgeries are ineffective as a long-term remedy for hip arthritis because they, like many other treatments, have not been demonstrated to re-grow cartilage. As drastic as it sounds, hip replacement remains a popular option for patients with hip arthritis because

1) other less drastic measures have stopped working,

2) it works well,

3) is durable (lasts a long time), and

4) has a low complication rate.

For each of the last few years in the United States alone, over 400,000 hip replacements have been done each year. Hip resurfacing is very similar to hip replacement, the differences between the two will be detailed below.

In a hip replacement, the arthritic bone of the ball and socket are removed and replaced with an artificial ball and socket. The ball is typically metal and sits atop a titanium stem inserted inside the femur.) The socket has a smooth liner that the ball fits into and rubs on during motion. This smooth liner of the socket is fixed inside a thin titanium mesh that fits inside the patient’s socket. The patient’s bone grows into the titanium parts of the stem (in the femur) and socket. The surgery requires an incision 4 – 7 inches and takes approximately 1.5 – 2.5 hours to perform. Patients are usually in the hospital 3 nights before they are comfortable going home. Total recovery duration is 2 – 4 months before patients are back doing most things they want.

There are several options when it comes to hip replacement. Surgeons and patients can choose from different implants (such as ceramic ball and socket combinations), and surgical approaches to the hip. Much has been lately about two-incision and anterior approaches. Knowing which of these is best for you can only be determined by talking to your orthopedic surgeon.

Hip resurfacing is very similar to hip replacement in that the arthritic bone of the ball and socket are removed and replaced with an artificial ball and socket. For a variety of reasons, more has been made of the difference between hip replacement and resurfacing than has been discussed about the similarities. The differences include the facts that resurfacing requires the removal of less bone, permits the use of a larger ball, and use of a metal ball rotating in a metal socket (“metal-on-metal”). The disadvantages of resurfacing compared to hip replacement include the production of metal debris worrisome for serious side effects and the possibility of experiencing a particular hip fracture that does not occur after hip replacement. The advantages of hip resurfacing over hip replacement include a lower dislocation rate, the durability of a metal ball and socket, and the relative ease of “re-do” or revision surgery required in the unusual circumstances of loosening of the original components. For these and some other reasons, some hip surgeons consider resurfacing for younger patients with hip arthritis. Questions about resurfacing and replacement can be answered by your orthopedic surgeon.

Click here or select the image below to watch A Patient's Guide to Knee and Hip Replacement, video provided by Durango Orthopedics in Colorado for patient education.

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Labrum

The hip labrum lines the edge of the socket of the hip. It’s a flexible leathery structure which seems to have some role in protecting the edge of the socket while the thigh bone is rotating about. It’s similar to the meniscus of the knee, or even more accurately, the labrum of the shoulder. Like other tissues about the body, the labrum can tear. Sometimes patients with a torn labrum recall a specific injury at the time their symptoms began, but oftentimes they do not recall such an event. Patients with a torn labrum often experience pain coming from the groin, buttock, or outside part of the hip region. It can occur with changes in position, such as standing from a seated position, or bending the hip up in a way that brings the knee toward the chest. Some patients experience pain with or after physical activities, such as walking or sports. Sometimes there is pain at night that disturbs sleeping. The pain can be sharp, or can be accompanied by a sound of a snap or clunk coming from inside the hip joint. The pain coming from a torn labrum seems to remain relatively constant over times, some patients describing symptoms remaining relatively unchanged over years.

Diagnosing tears of the labrum can be accurately done by your orthopedic physician experienced in treating this diagnosis. The process requires a visit to their office, where the physician will listen to your symptoms and review other relevant facts about your history, then perform a physical examination. X-rays are often obtained to rule out more common causes of hip pain, such as arthritis. X-rays are usually normal in patients who have only a torn labrum, mostly because x-rays show only structures that have bone in them and the labrum has no bone in it - therefore it is invisible to x-rays. An MRI is often required to diagnose a torn labrum, and sometimes the physician with whom you are working will request the MRI be done with a special fluid called gadolinium or contrast. The contrast fluid improves the accuracy of the MRI and is therefore a good idea if the diagnosis is unclear. The downside is that the contrast fluid has to be injected into the hip joint by a needle prior to the MRI.

Treatment

Treating labrum tears usually starts with options that are cheap, safe, and simple for the patient. Patients can choose to avoid or minimize the activities that cause the symptoms. Medicines such as Tylenol (acetaminophen) and NSAIDS (non-steroidal anti-inflammatories such as ibuprofen, or Aleve) can help control the pain from a torn labrum. Physical therapy, chiropractic manipulation, weight loss, acupuncture, massage therapy, supplements and other treatments can also be tried. Cortisone injection into the hip joint can also temporarily relieve the pain. Often however, despite the best of intentions, the labrum remains torn after these measures, and continues to generate pain. If the pain is bad enough, patients will sometimes undergo hip arthroscopy (“hip scope”) in which the torn part of the labrum is trimmed away or sewn back together. This outpatient (“day surgery”) procedure takes approximately an hour to perform, and the recovery takes a few weeks to a few months, depending on your surgeon and the nature of the procedure performed. Your hip arthroscopy physician can help you determine whether hip arthroscopy is right for you.

Visiting one of our physicians can help determine whether a patient with hip pain has arthritis. The physician will typically listen to the patient’s description of their symptoms, ask some questions and review other information from the patient’s medical history. A non-invasive physical examination then usually follows. X-rays usually show significant abnormalities if arthritis exists, and can be obtained at the time of the evaluation. Other tests (such as MRI) are usually not required to detect arthritis, but may be considered in some circumstances.

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Stress fractures

Stress fractures around the hip are rare, but do indeed occur. They usually affect the upper part of the femur just below the ball (femoral neck). They seem to occur when the work load is too great for the bone to support. Bone, like other support structures (like a beam in a building) has a limit to how much load it can bear. If the load exceeds this limit, the support structure, in this case the bone, fails, and a stress fracture (or worse, a complete fracture) occurs.

Stress fractures tend to occur in those who ramp up their activity level quickly, such as military recruits and others starting a vigorous running program, for example. They may also occur in elderly patients or those with bones made weak by medical conditions (osteopenia or osteoporosis). Patients with a stress fracture of the hip will tend to have groin pain that worsens with weight bearing activity, and improves when weight bearing stops, such has when the patient rests by sitting or lying down.

The diagnosis of a hip stress fracture can be made by your orthopedic physician, and requires a visit to their office. At this visit, the physician will ask you to describe your symptoms and review other parts of your medical history. A physical examination will follow and x-rays would likely be obtained. Often, other tests are required, such as an MRI or bone scan.

The good news is that most stress fractures heal perfectly without surgery. Most simply take time for the bone to heal, a period during which crutches (or a walker) would be used to help keep weight off the injured leg for 4-8 weeks. It would be reasonable to expect most patients to eventually return to all activities such as work and sports once things have healed completely. Naturally during this time, the physician can begin addressing any factors that could have predisposed the patient to the stress fracture in the first place in order to decrease the chances of another stress fracture happening again in the future.

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Hip Fractures

Fractures of the bones of the hip are among the more common fractures in the elderly. With age, bone strength declines such that a simple fall can cause the weakened bone to break, or fracture. Hip fractures can occur in younger patients, but usually they result from bigger forces such as a car wreck, or a fall off a roof, for example.

Symptoms of a fractured hip include pain, usually so severe that the patient cannot get up off the floor or walk. Motion of the hip likewise is very painful. Patients with a hip fracture usually have to be transported to the hospital by ambulance to be evaluated and treated. Once at the hospital, patients will undergo a discussion of the history of their injury plus a review of their medical history, a process usually performed by an emergency room physician. The diagnosis is typically confirmed by x-rays, at which point an orthopedic physician is contacted by the emergency room.

Treatment

Treatment of hip fractures is complex. Deciding how to treat a given fracture requires the patient, family, and orthopedist and others physicians to come to a complete understanding of many issues, including the specific fracture type, the different treatment options, other medical problems the patient may have, the patient’s pre-fracture activity level, the patient’s mental status, and the family’s wishes, plus others. Treatment of the elderly patient with a hip fracture requires a broad array of care professionals, often including internal medicine physicians, cardiologists, anesthesiologists, and other physician specialists all pitching in to make sure the patient receives the best quality care. Similarly, a large spectrum of nurses, physical therapists, occupational therapists, social workers, and other ancillary providers contribute their significant skills to the patient’s care. Treatment options include non-operative management versus surgery; and the surgical options include insertion of screws across the fracture all the way up to hip replacement, again depending on the factors described above. Recovery can last months, and sometimes the elderly patient never gets back to the level of function they had prior to the fracture. It is a difficult and complicated time, making it very important for the patient, family, and health care team to be openly communicating about the issues affecting care decisions. For more information about hip fractures, please ask your orthopedic physician.

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