Hip Injuries and Tears

Hip pain, one of the common symptoms patients complain of, may not always be felt precisely over the hip joint. Pain may be felt in and around the hip joint and the cause for pain is multifactorial. The exact position of your hip pain suggests the probable cause or underlying condition causing pain. Pain felt inside the hip joint or your groin area is more likely to be because of the problems within the hip joint. Likewise, the pain felt on the outer side of your hip, upper thigh or buttocks may be a result of the problems of the muscles, ligaments, tendons and soft tissues surrounding the hip joint. However certain disease conditions affecting other parts of your body such as lower back or knees also cause hip pain.

The main cause of sudden pain in the hip is an injury resulting in fracture of the hip bone. Hip fractures are common in the elderly individuals because the bones wear out as age advances. Other causes of hip pain may be arthritis, bursitis, infection, low back pain, osteonecrosis of the hip, sprains or strains and tendinitis resulting from repetitive use. Your doctor will evaluate the condition based on the medical history, physical examination of the hip and thigh region, and diagnostic tests including X-rays and other scans.

Self-care and pain relieving anti-inflammatory medications offer symptomatic relief. However, the exact cause for the pain needs to be addressed. Practicing certain measures can avoid aggravation of pain and improve the quality of life. Avoiding physical activities that may worsen the pain, stretching the quadriceps and hamstring muscles, performing warm up exercises before actual exercise regimen improve the condition. Applying ice packs over the region of pain for about 15 minutes three to four times daily reduces both pain and swelling. But if you have an injury with severe hip pain and swelling, talk to your orthopedic surgeon immediately for better treatment outcomes.

A tear in the muscle fibers caused by either a fall or direct blow to the muscle, overstretching and overuse injury is called a strain. Muscle strains often occur in the hip region whenever a muscle contracts suddenly from its stretched position. It can be mild, moderate or severe and depends on the level of injury. The chances of having a hip muscle strain becomes high if you have had a previous injury in the area or if there is no warm-up before exercising. The most common symptom of hip strain is pain and swelling in the area of injury. Pain may worsen on using the injured muscle and the strength in the muscle may also decrease.

Apart from physical examination of your hip and leg, your doctor may order an X-ray to rule out a stress fracture of the hip and confirm the diagnosis. Initial treatment aims at relieving pain and swelling. RICE protocol should be followed for mild to moderate strains. It includes:

• R-Rest: Avoid bearing excess weight on your hip. You should use crutches for the first 1-2 days after injury.
• I- Ice: Gently rub the area with ice. This decreases the swelling.
• C-Compression: Wrap a bandage over the area to help decrease the swelling.
• E-Elevation: Elevate the injured area above heart level.

Anti-inflammatory medications may also be prescribed to reduce swelling and pain. In the initial two days, your doctor may recommend application of heat to the area using hot soaks or heating pads. It is beneficial to be away from activities that causes the strain for 2 weeks. During this period, simple stretching and strengthening exercises can be done to regain muscle strength.

Preventing hip strains

You can practice certain techniques to avoid straining the muscles around your hip. Stretching your muscles before starting any exercise or sport activity significantly reduces your risk. Also, remember to stretch the muscles slowly and hold the stretch for some time instead of making large number of rapid stretches.  Warm up every time before you stretch. Participate in conditioning program to keep your muscles flexible and fit always. Use protective gear that is appropriate for the sports activity you are involved.

Hip bursitis is a painful condition caused by inflammation of a bursa in the hip. Bursae are fluid filled sacs present in joints between bone and soft tissue to reduce friction and provide cushioning during movement.

The bony prominence of the hip is called greater trochanter and is present on the outer side of the upper thigh bone or femur. The bursa overlying it is called trochanteric bursa. Another bursa is located towards the groin region and is called iliopsoas bursa. Bursitis of the trochanteric bursa is more common than that of iliopsoas bursa.

Causes

Trochanteric bursitis is often seen in people involved in sports such as football and soccer which involve a lot of running. This can lead to overuse and irritation of the bursa causing inflammation. Bursitis may sometimes result from an injury or fall to the hip or after a surgical procedure of the hip. Spine disease, rheumatoid arthritis and leg length inequality increases the risk for developing hip bursitis.

Symptoms

Trochanteric bursitis results in pain on the outer side of the hip which usually increases with prolonged walking or climbing stairs. The pain is felt more while getting up from a chair and in the night when lying on the affected side. Inflammation of the iliopsoas bursa however results in pain in the groin region.

Diagnosis

Tenderness and swelling in the area of pain over the bursa during the physical examination of the hip confirms the diagnosis of Hip Bursitis. To check for any bone spurs that could be causing irritation of the bursa your doctor may order an X-ray. If the reason for the pain is not very clear the doctor may order an MRI to view the soft tissues and structures not visible on X-ray.

Conservative Treatment Options

Treatment goals for bursitis are focused on resolving the inflammation and pain. Rest is advised and activities causing the bursitis pain are restricted. Anti-inflammatory medications are prescribed to reduce the inflammation and pain. Physical therapy and treatments with heat, ice and ultrasound sometimes are recommended. An injection of corticosteroid medicine may be administered to reduce the inflammation. Sometimes a second injection is necessary if the pain returns after a few months. These nonsurgical treatments provide relief from hip bursitis in most cases.

Femoroacetabular impingement (FAI) is a condition where there is too much friction in the hip joint from bony irregularities causing pain and decreased range of hip motion. The femoral head and acetabulum rub against each other creating damage and pain to the hip joint. The damage can occur to the articular cartilage (the smooth white surface of the ball or socket) or the labral tissue (the lining of the edge of the socket) during normal movement of the hip. The articular cartilage or labral tissue can fray or tear after repeated friction. Over time, more cartilage and labrum is lost until eventually the femur bone and acetabulum bone impact on one other. Bone on bone friction is commonly referred to as Osteoarthritis.

FAI impingement generally occurs as two forms: Cam and Pincer.

CAM Impingement: The Cam form of impingement is when the femoral head and neck are not perfectly round, most commonly due to excess bone that has formed. This lack of roundness and excess bone causes abnormal contact between the surfaces.

PINCER Impingement: The Pincer form of impingement is when the socket or acetabulum rim has overgrown and is too deep. It covers too much of the femoral head resulting in the labral cartilage being pinched. The Pincer form of impingement may also be caused when the hip socket is abnormally angled backwards causing abnormal impact between the femoral head and the rim of the acetabulum.

Most diagnoses of FAI include a combination of the Cam and Pincer forms.

Symptoms of FAI

Symptoms of femoroacetabular impingement can include the following:

• Groin pain associated with hip activity
• Complaints of pain in the front, side or back of the hip
• Pain may be described as a dull ache or sharp pain
• Patients may complain of a locking, clicking, or catching sensation in the hip
• Pain often occurs to the inner hip or groin area after prolonged sitting or walking
• Difficulty walking uphill
• Restricted hip movement
• Low back pain
• Pain in the buttocks or outer thigh area

Risk Factors

A risk factor is something that is likely to increase a person’s chance of developing a disease or condition. Risk factors for developing femoroacetabular impingement may include the following:

• Athletes such as football players, weight lifters, and hockey players
• Heavy laborers
• Repetitive hip flexion
• Congenital hip dislocation
• Anatomical abnormalities of the femoral head or angle of the hip
• Legg-Calves-Perthes disease: a form of arthritis in children where blood supply to bone is impaired causing bone breakdown.
• Trauma to the hip
• Inflammatory arthritis

Diagnosis

Hip conditions should be evaluated by an orthopedic hip surgeon for proper diagnosis and treatment.

• Medical History
• Physical Examination
• Diagnostic studies including X-rays, MRI scans and CT Scan

Treatment Options

Conservative treatment options refer to management of the problem without surgery. Nonsurgical management of FAI will probably not change the underlying abnormal biomechanics of the hip causing the FAI but may offer pain relief and improved mobility.

Conservative treatment measures

• Rest
• Activity Modification and Limitations
• Anti-inflammatory Medications
• Physical Therapy
• Injection of steroid and analgesic into the hip joint

Surgical treatment

Hip arthroscopy to repair femoroacetabular impingement is indicated when conservative treatment measures fail to provide relief to the patient.

Avascular necrosis, also called osteonecrosis is a condition in which bone death occurs because of inadequate blood supply to it. Lack of blood flow may occur when there is a fracture in the bone or a joint dislocation that may damage nearby blood vessels. Chronic use of high doses of steroid medications and heavy alcohol consumption are the two main risk factors of avascular necrosis. Initially, small breaks appear in the bone that may eventually collapse. Hip joint is most commonly affected; however, the knee and shoulder may also be involved. 

The symptoms appear suddenly if it’s a result of an injury. In other situations, the pain and stiffness may gradually appear over a period. Typically, avascular necrosis causes pain and restricted range of motion in the joint affected. Your doctor will diagnose the condition using imaging tests such as X-rays, MRI scan and bone scan that help rule out other causes of joint pain.

The treatment for avascular necrosis aims at preventing further loss of bone and it depends on the bone damage that has occurred already. Conservative treatment would reverse early stages of avascular necrosis whereas surgical treatment may be required in more advanced stages.

Conservative approach

• Medications: Non-steroidal anti-inflammatory drugs (NSAID’S) may be prescribed that help control your pain and swelling
• Rest: Restriction of physical activities and use of crutches to decrease weight bearing on your joints may be beneficial
• Exercises:  Regular exercises that improve your range of motion may be done
• Electrical stimulation: Electric currents promote new bone growth. They can be applied directly to the area of damage or through electrodes fixed on skin. It helps replace the damaged bone

Surgical Treatment

• Core decompression: During this procedure, a portion of the inner layer of the bone is removed to relieve the pressure inside the bone. This decreases the pain and allows growth of new blood vessels thereby stimulates new bone growth
• Joint replacement: Joint replacement surgery is done as a last resort when the bone has collapsed needing artificial replacement

The hip joint is a “ball and socket” joint. The “ball” is the head of the femur, or thigh bone, and the “socket” is the cup shaped acetabulum. The joint surface is covered by a smooth articular surface that allows pain free movement in the joint.

Hip fracture is a break that occurs near the hip in the upper part of the femur or thigh bone. The thigh bone has two bony processes on the upper part - the greater and lesser trochanters. The lesser trochanter projects from the base of the femoral neck on the back of the thigh bone. Hip fractures can occur either due to a break in the femoral neck, in the area between the greater and lesser trochanter or below the lesser trochanter.

Hip fracture is most frequently caused after minor trauma in elderly patients with weak bones, and by a high-energy trauma or serious injuries in young people. Long term use of certain medicines, such as bisphosphonates to treat osteoporosis (a disease causing weak bones) and other bone diseases, increases the risk of hip fractures.

Signs and symptoms

Signs and symptoms of hip fracture include:

• Pain in the groin or outer upper thigh
• Swelling and tenderness
• Discomfort while rotating the hip
• Shortening of the injured leg
• Outward or inward turning of the foot and knee of the injured leg

Your doctor may order an X-ray to diagnose your hip fracture. Other imaging tests, such as the magnetic resonance imaging or (MRI), may also be performed to detect the fracture.

Depending on the area of the upper femur involved, hip fractures are classified as

• Intracapsular Fracture
• Intertrochanteric Fracture
• Subtrochanteric Fracture

Hip fractures can be corrected and aligned with non-operative and operative methods:

Traction may be an option to treat your condition if you are not fit for surgery. Skeletal traction may be applied under local anesthesia, where screws, pins and wires inserted into the femur, and a pulley system is set up at the end of the bed to bear heavy weights. These heavy weights help in correcting the misaligned bones until the injury heals.

Hip fractures can be surgically treated with external fixation, intramedullary fixation, or by using plates and screws.

A hip labral tear is an injury to the labrum, the cartilage that surrounds the outside rim of your hip joint socket. The hip joint is a ball and socket joint in which the head of the femur is the ball and the pelvic acetabulum forms the socket. The labrum helps to deepen the socket and provide stability to the joint. It also acts as a cushion and enables smooth movements of the joint.

Causes

A tear in the labrum of the hip can result from traumatic injury, such as a motor vehicle accident or from participating in sports such as football, soccer, basketball, and snow skiing. These sports are associated with sudden changes of direction and twisting movements that can cause pain in the hip.  Repetitive movements and weight bearing activities over time can lead to joint wear and tear that can ultimately result in a hip labral tear. Degenerative changes to the hip joint in older patients can also lead to a labral tear.

Symptoms

Many patients with a hip labral tear do not have symptoms. However, some patients may experience pain in the hip or groin area, a catching or locking sensation in the hip joint, or significant restriction in hip movement. 

Diagnosis

Your doctor will order certain tests to determine the cause of your hip pain.

X-rays of the hip allow your physician to rule out other possible conditions such as fractures or structural abnormalities.

Magnetic resonance imaging (MRI) may also be used to evaluate the labrum. An injection of contrast material into the hip joint space at the time of the MRI can help show the labral tears much clearer.

Injection of local anesthetic into the joint space is sometimes performed to confirm the location of the pain. If the injection completely relieves your pain, it is likely that the cause of the problem is located inside the hip joint.

Treatment Options

Treatment for a hip labral tear will vary depending on the severity of the condition. People with a minor labral tear recover within a few weeks with the help of non-surgical treatments.

Conservative treatments include:

• Medications: Anti-inflammatory medications can be helpful in relieving pain and reducing inflammation associated with labral tears. Your doctor may also recommend cortisone injections to alleviate the pain associated with a hip labral tear.
• Physical therapy: Physical therapy that helps to improve hip range of motion, strength, and stability are also recommended.

However, severe cases may require arthroscopic surgery to remove or repair the torn portion of the labrum.

Surgery

Hip arthroscopy, also referred to as keyhole surgery or minimally invasive surgery, is a surgical procedure in which an arthroscope, a narrow tube with a tiny camera on the end, is used to assess and repair damage to the hip.

The surgery is performed with the patient under general, spinal or local anesthesia.

Your surgeon will make 2 or 3 small incisions around the hip joint area. The arthroscope is inserted into the hip joint through one of the incisions to view the labral tear. The camera attached to the arthroscope displays the image of the joint on the monitor. A sterile solution will be pumped into the joint to have a clear view and room to work. Through the other incisions specially designed instruments are inserted. Your surgeon repairs the torn tissue by sewing it back together or removes the torn piece all together, depending upon the cause and extent of the tear. After the completion of the procedure, the arthroscope and instruments are removed and the incisions are closed.

Post- Operative Care

Following the surgery, you will be given instructions on caring for your incisions, activities to avoid and exercises to perform for a fast recovery and a successful outcome.  Physical therapy will be recommended by your doctor to restore your strength and mobility.  Your doctor will also prescribe pain medications to keep you comfortable.

Risks and Complications

Possible risks and complications specific to arthroscopic hip surgery include:

• Infection
• Deep vein thrombosis(DVT)
• Blood vessel or nerve damage
• Hemarthrosis (bleeding inside the joint)
• Failure to relieve pain

A hip fracture is a break that occurs near the hip in the upper part of the femur or thigh bone. The thigh bone has two bony processes on the upper part - the greater and lesser trochanters. The lesser trochanter projects from the base of the femoral neck on the back of the thigh bone. Hip fractures can occur either due to a break in the femoral neck, in the area between the greater and lesser trochanter or below the lesser trochanter.

Subtrochanteric hip fracture is a break between the lesser trochanter and the area approximately 5 centimeters below the lesser trochanter. The fracture can be classified based on its location:

Type I occurs at the level of the lesser trochanter,

Type II occurs within 2.5 cm below the lesser trochanter and, Type III occurs between 2.5 and 5cm below the lesser trochanter.

Causes

A subtrochanteric hip fracture is most frequently caused from minor trauma in elderly patients with weak bones, and by high-energy trauma in young people. Long term use of certain medicines, such as bisphosphonates to treat osteoporosis (a disease causing weak bones) and other bone diseases, increases the risk of subtrochanteric hip fractures.

Signs and Symptoms

Signs and symptoms of subtrochanteric hip fracture include

• Pain in the groin or outer upper thigh
• Swelling and tenderness
• Discomfort while rotating the hip
• Shortening of the injured leg
• Outward or inward turning of the foot and knee of the injured leg

Diagnosis

Your doctor may order an X-ray to diagnose subtrochanteric hip fracture. Other imaging tests, such as magnetic resonance imaging (MRI) may also be performed to detect the fracture.

Treatment

A subtrochanteric fracture can be corrected and aligned with non-operative and operative methods. Traction may be an option to treat your condition if you are not fit for surgery. Skeletal traction may be applied under local anesthesia, where screws, pins and wires are inserted into the femur, and a pulley system is set up at the end of the bed to bear heavy weights. The heavy weights help in correcting the misaligned bones until the injury heals.

Surgery

Surgery is usually the main treatment for subtrochanteric fractures. Surgical options include external fixation, intramedullary fixation or by using plates and screws.

External fixation is a temporary fixation and used for severe open fractures. Pins are inserted into each of the fractured fragment and supported with tubes close to the bone. The tubes are interconnected together with short tubes to provide more stiffness for the frame.

Intramedullary fixation involves managing the fracture with a long intramedullary nail which is fixed with a large screw. Additional screws known as interlocking screws are inserted at the lower end of the nail to prevent rotation of bones around the nail.

You surgeon may use a plate with screws attached instead of a nail in certain cases. Screws will be fixed into the bone from the outer side of the femur. A large screw will be inserted through the femoral neck and head, and other screws will be inserted across the length of the plate to hold the fracture together.

Risks and Complications

As with any surgical procedure, surgery for a sub trochanteric fracture involves certain risks and complications including:

• Nonunion of fracture with pain
• Limp or limited hip rotation due to malunion
• Nail or screw fixation failure
• Wound infection

Hip synovitis, also called transient hip synovitis or toxic synovitis is a condition in which there is inflammation of the synovial tissues surrounding the hip joint causing hip pain. It is the most common reason for sudden hip pain occurring in young children between the age of 2 and 9. It affects boys more commonly than girls and most of the times, the hip joint on only one side is affected.

The symptoms of hip synovitis manifest over a period of 1 to 3 days and gradually resolve within the next few days. The most common symptom is pain around the hip or groin region. The child may limp while walking or may find it hard to walk. Sometimes, the child has a low-grade fever or complains of pain in the inner thigh or knee.

The exact cause of hip synovitis is unknown, but some theories include a history of trauma to the hip or a recent viral infection such as an upper respiratory tract infection, bronchitis or middle ear infection.

When you go for a consultation, your doctor will initially examine your child’s hip, knee and other joints and check whether there is pain while moving the joints passively. Your doctor may order diagnostic tests such as ultrasound imaging and blood tests to assess inflammatory markers. If the inflammatory markers are high, then your doctor may order a culture test of the fluid within the joint. To perform the culture test, joint fluid is collected by inserting a needle into the hip joint and aspirating the fluid then sending it to lab for evaluation.

The treatment for hip synovitis includes simple home remedies such as rest, application of heat and massage over the painful area. Anti-inflammatory medications will be prescribed to reduce the pain and other symptoms. Weight bearing on the affected side should be avoided until pain is resolved.

Tendons are strong connective tissue structures that connect muscle to bone. Hip tendonitis is a condition associated with degeneration of the hip tendons. This condition is mainly caused due to strain on the tendons which may be due to overuse, or biomechanical problems.

Symptoms of hip tendonitis include:

• Pain which increases gradually
• Tenderness in the hip joint
• Stiffness of the hip
• Difficulty in movement or stretching of the muscle

Hip tendonitis can be treated with the help of RICE: rest, ice, compression and elevation. You may also be referred to a physical therapist who will instruct you on stretching exercises to regain motility, Massage and ultrasound therapy may also be recommended to enhance recovery.

Developmental dysplasia of the hip (DDH) or Hip dysplasia is a condition which is seen in infants and young children because of developmental problems in the hip joint. The femur (thigh bone) partially or completely slips out of the hip socket causing dislocation at the hip joint. It is most common in first born baby with family history of the disorder. The exact cause for hip dysplasia is not known. Genetic factors play an important role in causing this birth defect. DDH can be mild or severe and can affect one or both hips. It is more common in girls and usually affects the left hip. DDH does not cause any pain and so the condition may not be noticed until the child starts to walk. 

The common symptoms of hip dysplasia include:

• Position of the legs may differ (dislocated hip may cause leg on that side to turn outwards)
• Restricted movement on the side of hip dislocation
• The leg may appear shorter on the side where hip is dislocated
• Skin folds of fat on the thigh or buttocks may appear uneven.

In normal hip, the head of the femur (thigh bone) fits well into the socket (acetabulum) whereas in hip dysplasia, the socket and femoral head are not congruent because of their abnormal development. During hip examination, the doctor may also look for the difference in range of motion of the hip, presence of uneven skin folds around the thigh and difference in leg length from side to side. In infants less than 6 months, an ultrasound may be advised to confirm the diagnosis.

The treatment for DDH depends on both the age of the child and severity of the condition. The aim of treatment is to keep the femoral head in good contact with the acetabulum so that the hip can develop normally. A pavlik harness may be used to keep the hip in flexion and abduction may be advised. Only when conventional treatment is not effective, surgery to put the hip back into place may be advised.