Back Clinic Hip Pain & Disorders Team. These types of disorders are common complaints that can be caused by a variety of problems. The precise location of your hip pain can give more information about the underlying cause. The hip joint on its own tends to result in pain on the inside of your hip or groin area. Pain on the outside, upper thigh, or outer buttock is usually caused by ailments/problems with the muscles, ligaments, tendons, and soft tissues surrounding the hip joint. Hip pain can also be caused by diseases and conditions in other areas of your body, i.e. the lower back. The first thing is to identify where the pain is coming from.
The most important distinguishing factor is to find out if the hip is the cause of the pain. When hip pain comes from muscles, tendons, or ligament injuries, it typically comes from overuse or Repetitive Strain Injury (RSI). This comes from overusing the hip muscles in the body i.e. iliopsoas tendinitis. This can come from tendon and ligament irritations, which typically are involved in snapping hip syndrome. It can come from inside the joint that is more characteristic of hip osteoarthritis. Each of these types of pain presents itself in slightly different ways, which is then the most important part in diagnosing what the cause is.
Injuries to the muscles and ligaments around the hip affect both competitive and recreational athletes. These injuries can interfere significantly with sports enjoyment and performance levels, and they occasionally will end participation completely. Excessive pronation and poor shock absorption have been found to be an underlying cause or a contributing factor for many leg injuries. Functional orthotics which have been custom-fitted to improve the biomechanics of the feet and reduce the extent of pronation can help to prevent many sport-related leg injuries.
Lower Extremity Problems in Athletes
One study looked at the foot biomechanics of athletes who reported a recent foot or leg injury and compared them to an uninjured control group. The researchers determined that those athletes with more foot pronation had a much greater statistical probability of sustaining one of five leg injuries, including iliotibial band syndrome (which is due to excessive tightness of the hip abductor muscles).
This study helps us understand how providing appropriate functional foot orthotic support to patients who are involved in sports or recreational activities lowers their likelihood of developing both traumatic and overuse hip injuries.
In this paper, sixty-six injured athletes who ran at least once a week, and who had no history of traumatic or metabolic factors, were the study group. Another control group of 216 athletes were matched who did not have any symptoms of lower extremity injuries. The amount of pronation during standing and while running at �regular speed� was determined by measuring the angles of their footprints. The investigators found a significant correlation: Those athletes with more pronation had a much greater likelihood of having sustained one of the overuse athletic injuries.
Hip and Thigh Injuries
Many injuries experienced at the hip develop from poor biomechanics and gait asymmetry, especially when running. Smooth coordination of the muscles that provide balance and support for the pelvis is needed for optimum bipedal sports performance. This includes the hamstring muscles and the hip abductor muscles, especially the tensor fascia lata (the iliotibial band). When there is a biomechanical deficit from the feet and ankles, abnormal motions (such as excessive internal rotation of the entire leg) will predispose to pulls and strains of these important support muscles. The hamstrings (comprised of the biceps femoris, semimembranosus, and semitendinosus muscles) are a good example.
During running, the hamstrings are most active during the last 25% of the swing phase, and the first 50% of the stance phase. This initial 50% of stance phase consists of heel strike and maximum pronation. The hamstring muscles function to control the knee and ankle at heel strike and to help absorb some of the impact. A recent study has shown a significant decrease in electromyographic activity in the hamstrings when wearing orthotics. In fact, these investigators found that the biceps femoris (which is the most frequently injured of the three hamstring muscles) had the greatest decrease in activity of all muscles tested, including the tibialis anterior, the medial gastrocnemius, and the medial and lateral vastus muscles. The scientists in this study theorized that the additional support from the orthotics helped the hamstrings to control the position of the calcaneus and knee, so there was much less stress into the hip joint and pelvis.
Excessive Pronation and Hip Injuries
Using functional orthotics to correct excessive pronation and to treat hip problems requires an awareness of the various problems that can develop. The following is a list of the pathologies that are seen in the hip and pelvis secondary to pronation and foot hypermobility:
Iliotibial band syndrome����������������� Tensor fascia lata strain
Trochanteric bursitis����������������������� Hip flexor muscle strain
Piriformis muscle strain������������������ Hip adductor muscle strain
Hip joint capsulitis��������������������������� Anterior pelvic tilt
These conditions will develop much more easily in athletes, who push their musculoskeletal systems, and who seek more efficient and effective functional performances.
In 2002, researchers at Logan College of Chiropractic recruited a total of 40 male subjects that demonstrated bilateral pes planus or hyperpronation syndrome. Subjects were cast for custom made orthotics; their right and left Q-angles were measured with and without the orthotic in place. Thirty-nine of 40 test subjects showed reduced Q-angle, which was in the direction of correction, suggesting that wearing orthotics can improve stability and levelness of the pelvis, thus protecting the body to some degree from hip injury.
Conclusion
Excessive pronation and/or poor shock absorption have been shown to be an associated or causative factor in many leg injuries � from the foot itself, up the lower leg to the knee, thigh, and into the hip joint. The good news is that many of these conditions can be prevented with custom-fitted functional orthotics. Evaluation of foot biomechanics is a good idea in all patients, but is especially necessary for those who are recreationally active, or for anyone who has experienced hip problems.
To avoid potentially disabling hip injuries, competitive athletes must have regular evaluations of the alignment and function of their feet. Additional preventive measures include wearing well-designed and solidly-constructed shoes. When athletes are provided with custom-fitted functional orthotics, it can help prevent arch breakdown and biomechanical foot problems, and also treat numerous injuries of the lower extremities, including the hip joints.
Many injuries experienced at the hip develop from poor biomechanics and gait asymmetry, especially when running. Smooth coordination of the muscles that provide balance and support for the pelvis is needed for optimum bipedal sports performance. For Answers to any questions you may have please call Dr. Jimenez at 915-850-0900
Women often seek out chiropractic care during their pregnancies. One of the main reasons for this is that if they are having musculoskeletal pain, their Obstetrician or Midwife generally has very limited options for conventional medical treatment. They are less likely to prescribe medication, which presents an amazing opportunity for us as chiropractors. What initially began as a strange combination of a sports certification and a prenatal/pediatric certification has created a successful and in-demand niche for us. For the most part, I cannot imagine treating prenatal patients without having the sports background. First, most women at some point in their lives have been or currently are an athlete. And second, one of the most common complaints women have during pregnancy is myofascial pain, and who better to treat that than a sports chiropractor? Here are 5 common and easy-to-treat complaints during pregnancy:
One: Pubic Bone Pain
This pain is very common during the second and third trimesters of pregnancy. Women will often describe it as exquisitely tender, worse with rolling over in bed at night, walking or climbing stairs. Conventional medical opinion is that the ligaments during pregnancy are much more relaxed (due to the hormone, relaxin) causing separation of the pubic symphysis and thus inflammation and pain. Sports chiropractors are uniquely qualified to assess this joint, and the common causes of pain can include:
1. Adductor hypertonicity easily addressed with myofascial release or techniques such as Graston, which can be done over leggings or on skin.
2. SI Joint fixation or Pubic Symphysis fixation. While I am generally a diversified adjuster, an activator adjustment to the superior or more-tender pubic rami will go a long way in terms of providing relief. I strongly discourage any audible manipulation of the pubic symphysis.
3.�Kinesiology taping�of a �RockTape Baby Belt� or modified version of this can provide significant relief and is much more comfortable than a pelvic support belt.
4. Using an ice pack for 15 minutes prior to going to bed at night will decrease pain and inflammation while sleeping.
Two: Rib Pain
Rib pain, especially in the lower and floating ribs, is common as the weight of the abdomen is pulling on the oblique abdominal muscles and their attachments at the ribs. Adjusting the ribs at the thoracic spine and incorporating myofascial release or Graston Technique will work quickly (often in just 1 treatment). Finish up with a few strips of kinesiology tape and your patient will feel significantly better.
Three: Upper Abdominal Numbness
Upper abdominal numbness is a common symptom during the later stage of pregnancy. It often presents as numbness but can also be painful and worse with sitting. One of the easiest ways to provide relief is with one simple strip of kinesiology tape over the top of the abdomen directly under the rib cage.
Four: Swelling in the arms and legs
Swelling in the arms and legs is very common and can lead to numbness, tingling or pain. Before beginning treatment, be sure to assess if the swelling in the feet is significant and test for pitting edema which can be a warning sign of preeclampsia. This can be corroborated with a high blood pressure reading and is very dangerous. Two very effective sports techniques for use with lower extremity swelling include 1.�NormaTec PULSE Recovery System�which is not contraindicated in pregnancy. Patients can do a few 20-30 minutes sessions per week to promote circulation and decrease swelling. 2. Kinesiology taping for edema on the ankles.
Five: Lower Back Pain
Lower back pain in pregnancy is very common. Evaluating a pregnant patient prone is very easy if you have pregnancy cushion that sits on top of your table. If you do not, you can evaluate the lower back in the seated or side lying position. Lower back pain can generally be addressed with diversified adjustments (without any rotation as to not stress the abdomen). In addition, the Webster Technique for pregnancy is a valuable tool for assessing and treating lower back pain during all stages of pregnancy. There are also valuable kinesiology tape applications for lower back pain,�RockTape features a pregnancy taping pdf online. In addition, there are no contraindications to using the Graston Technique to address myofascial pain in the lower back.�
Most of the taping techniques discussed above can be done by patients themselves after a one-time demonstration. Have an assistant or patient�s family member take a video of the application for reference at home. Many sports chiropractic techniques can be used very effectively on prenatal patients.
Hip injuries are often uncommon types of injuries among athletes, as these don�t generally occur immediately, rather, the accumulated hours of training may progressively cause a series of worsening symptoms.
Approximately 3.3 percent to 11.5 percent of long distance runners suffer sports injuries as a result of overtraining, where hip complications are believed to contribute for up to 14 percent of all athletic issues. In fact, hip injuries make up nearly a sixth of all injuries sustained by athletes. Moreover, because of the complexity of the hip and its surrounding structures, about 30 percent of hip injuries are undiagnosed. Without correcting the initial problem, recurrence or ongoing impairment may often follow.
Anatomy of the Hip
The hip can be described as a ball and socket joint, the ball constitutes from the head of the femur and the socket from the acetabulum of the pelvis. The depth of the socket is increased due to a specific type of tissue best known at the fibrocartilage lining of the labrum, which is almost identical to the cartilage found in the knee. The extra added depth to the acetabulum adheres the ball within the socket to allow the necessary stability to support the hip joint as well as its surrounding muscles and ligaments. The labrum is made up of multiple nerve endings which assist with the perception of pain and the awareness and balance of the joint within the body, referred to as proprioception. The structure provides forward, backward, and side to side movement to the hip, also allowing it to rotate inwards and outwards. This intricate mobility of the hip, together with the speed and power of running, is the main cause behind the different forms of hip injuries among athletes.
Running Biomechanics
To understand the mechanics of running and the process of impact which transfers through the body, the cycle of running can be explained into two phases. The first phase is called the stance phase, where the foot lands on the ground, and the second phase is called the swing phase, were the foot moves through the air. The stance phase initiates when the heel is in contact with the ground. Referred to as the mid-stance, this middle phase occurs when the rest of the foot follows, also referred to as the absorption phase. At this point, the knee and ankle are fully flexed in order to be able to absorb the impact against the ground, functioning as a brake to control the landing. The leg then saves this elastic energy within the muscles. The hip, knee and ankle subsequently extend using the recoil from the muscles to complete the toe-off phase and propel the body forward and upward.
During longer distance running, the stance phase generally lasts longer due to a runner�s longer stride. The stance phase also exposes the hip joint to about five times the individual�s body weight in comparison to three times the individual�s body weight during the swing phase. When athletes run faster, they spend less time on the ground, subjecting them to lesser forces being transmitted up their lower extremities.
The muscles and tissues of the hip, knee and ankle function together to control the movements of the joints and well as restrict the forces being placed against them. They are exposed to reaction forces from the ground which force the structures to contract accordingly. The harder and athlete lands or the greater the distance they run, the more activation is usually required by the structures to offload the joints and absorb the force of the additional load. As every runner possesses their unique running style, over a period of time, a constant pattern of running and the impact they receive from the above mentioned forces eventually exceeds an individual�s limit. This combination of factors is generally the leading cause of hip injuries among many athletes.
The Effects of Running on the Hip
Running impact occurs through the heel strike of the running phase. Depending on the duration of contact, the frequency and how heavy an athlete lands on their heel, the extent of impact will vary. Runners who impact on the midfoot are believed to experience far less impact force than other athletes.
As often described by many healthcare professionals, a single load can damage or injure the articular cartilage and tear the labrum, most commonly occurring after an unexpected trip or fall. Most often than not, however, the repetitive load from running or similar activities can gradually develop small micro trauma to the hip joint, an accumulation of damage which can thin out this layer of cartilage and cause tearing and shearing of the tissues. The hip consists of flexor muscles, such as the iliopsoas, the sartorius, the rectus femoris, the tensor fasciae latae and the pectineus, which are designed to flex in order to absorb the shock of impact. The pelvis will then follow by rotating back, providing more space for flexion to occur. It will then adduct, using the adductor longus, adductor brevis, adductor magnus and pectineus, which will then follow into abduction, primarily utilizing the gluteus medius, for a terminal swing and take off. The hip will then subsequently move into extension, where the leg extends backwards, to propel the body forward, mainly utilizing the gluteus maximus as the pelvis shifts forward to adjust the functions of the hip joint.
If any of these movements are altered during physical performance, the forces of impact being placed against the body will be transmitted incorrectly, causing the pelvis to become unstable and adding tremendous strain against the hip joints and muscles. Repetitive and constant loads of weight and force can then create an accumulation of trauma, leading to several forms of hip injuries and complications.
Hip Pathologies
A wide variety of hip injuries can affect running athletes as well as those involved in other types of sports and physical activities. The most common complications are as follows:
Muscle strains, can develop and affect any of the muscles and tissues involved in the natural biomechanics of the hip, specially if these become overloaded due to poor alignment and mechanics. The most common muscle strains causing hip injuries occur to the iliopsoas due to over flexing of the hip joint or from a heavy impact while the hip is flexed and an excessive amount of load is placed against the muscles. The gluteus medius can also suffer damage or injury if the runner or athlete over-adducts, described as an inwards movement of the hip, during their running pattern and the gluteus medius tendons become irritated with direct compression from the hip bone.
Trochanteric Bursitis, is characterized by swelling and inflammation of the fluid-filled sac known as the bursa, located within the greater trochanter on the side of the hip. The bursa provides the appropriate mobility to the iliotibial band found over the hip bone, however, constant shearing can often lead to irritation and inflammation.
Femoroacetabular impingement, or FAI, occurs when the femur compresses the acetabulum, primarily during the flexion of the hip where the bones and other structures collide. A pincer impingement where the acetabulum rim develops an extra lip of bone can often cause hip injuries or a CAM impingement can cause the femoral neck to grow an extra ridge of bone, resulting in other types of complications. Untreated FAI can progressively lead to labral tears because the additional bone can repeatedly grind down the labrum.
Labral tears, are medically defined as a tearing of the labrum which surrounds the joint of the hip and the acetabulum. These generally occur after a traumatic event or injury or due to cumulative microtraumas over a period of time.
Rehabilitation and Prevention
Because of the wide variety of hip injuries which can affect the modern athlete, a proper diagnosis performed by a qualified healthcare professional, such as a chiropractor or physical therapist, is absolutely essential towards developing an appropriate treatment plan. Foremost, athletes with already diagnosed hip injuries should avoid repeated or regular flexions of the hip to prevent further complications. If flexion cannot be avoided, for instance, when sitting, then the individual can lean back or stand up into extension. Cycling and treadmill running are not appropriate cross-training methods for hip injuries as these promote hip flexion and internal rotation, causing further impingement to the acetabulum. Swimming is permitted in these cases as it is a non-impact sport and it avoids these irritable positions.
The following three stages of rehabilitation can be followed in sequence or may be combined to prevent aggravating hip injuries.
First, the individual can proceed to strengthen the gluteal muscles, primarily the gluteus medius and maximus in isolation by performing the next exercise. The individual must bridge lie on their back while keeping their knees bent and placing their arms by their sides. Then, placing a resistance band around their thighs will help draw the knees in together. The individual may attempt to keep them apart by pushing against the band, activating the gluteus medius. Subsequently, the athlete can carefully push up through the heels to lift their buttocks and back off the floor, holding the position for five seconds before slowly returning to the initial position. This exercises should be repeated in sets of 10.
Also, the individual can perform another strengthening exercise by clam lying on their side with the specified hip on top. Keeping their feet together, the affected individual should then lift the top knee upwards into external rotation, activating the gluteus medius and preventing the hip from adducting. It�s important for the athlete to control their knee on the return to start position to maintain eccentric muscle control and improve greater hip stability. This exercise should be repeated for three sets of 10 repetitions.
Second, to strengthen the whole lower extremities, the individual must combine movements to incorporate other muscle groups and improve core stability. To achieve this, the individual must perform a lunge with twist by taking a step forward with their specified leg and proceed to bend both knees and hips simultaneously, making sure not to bend the hip to more than 60 degrees. Once in this particular position, the affected athlete can proceed to rotate their body from right to left, slowly returning to the starting position to strengthen the core and improve pelvic stability. This exercise should be repeated for sets of 10 as the participant is capable to do so.
Also, the individual can perform another exercise to strengthen the lower extremities known as the single leg squat with twist. Standing on the specified leg while the pelvis is in a neutral position, the athlete can proceed with this exercise by bending at the hip and knee into a squatting position. Keeping the knee behind the toes, the athlete must then rotate their body to the right and left while keeping their back straight, further activating the the gluteus maximus and challenging the core muscles. This exercise can be repeated in sets of 10 as able.
And finally, to strengthen the hip and improve the functional movements of running patterns, athletes with hip injuries can proceed to perform the following exercises. The standing hip hike can be completed by having the athlete stand upright with their feet kept hip distance apart. The individual must then hitch up their specified hip while maintaining neutral pelvic stability, making sure the hips do not twist or move around. Repeat for three sets of 10 repetitions.
Then, the individual can also perform forward step ups by standing in front of a high step or stair, holding on to a pole at one side to activate the latissimus dorsi back muscles, associated with the gluteal muscles. Leading with the chosen hip, the athlete can then proceed to step upwards and then return to the starting position. Repeat leading with the same leg each time for three sets of 10 repetitions.
Furthermore, to continue strengthening their hip and improve function, hip swings can be utilized to help those athletes with hip injuries throughout their rehabilitation process. Using a similar setup as the forward step ups, the individual can perform this exercise by resting their good knee on a bench. Holding on to the pole, the athlete can proceed to bring the specified hip forward into hip flexion, returning to the original position. The static leg should maintain good pelvic stability and will be brought into extension, activating the gluteus maximus rather than the hamstrings. This exercise must be repeated for three sets of 10 repetitions.
Return to Play
The athlete can participate in an appropriately developed return to play program following the variety of hip injuries they may experience, alongside the strength training regimen mentioned above once the complications begin to improve. Runners should aim to begin this specific program at approximately 60 percent pre-injury intensity. Athletes can begin running on soft surfaces to limit the amount of impact, they may include a comprehensive dynamic warm-up. Subsequently, athletes can begin progressively increase the speed, only running on alternate days for the first 3 to 4 weeks, continuing to strengthen through training. Sprints, hills, accelerations, and decelerations can be introduced slowly, choosing one element at a time.
As with any type of rehabilitating programs, the affected athletes must first seek medical attention from a qualified healthcare professional to receive a proper diagnosis of their injuries before attempting any form of stretches or exercises as to avoid further injuries. A chiropractor, is a specialized doctor who focuses on a variety of spinal injuries or conditions and its surrounding structures, including various types of sports injuries. Through chiropractic care, a chiropractor can perform a series of spinal adjustments and manual manipulations to provide mobilization therapy and improve an athlete�s symptoms, strength, flexibility and overall health. Doctors of chiropractic, or DCs, may also recommend a series of additional exercises different from the ones mentioned above to accordingly help speed up the individual�s recovery process.
Tips for Preventing Overuse and Traumatic Injuries
Hip injuries can be debilitating to runners as well as athletes from other sports. Hip flexibility and strength is essential for optimal performance. The hip joint is a complex structure that moves in multiple directions and is stabilized and supported by those specific structures. When an individual is faced with debilitating hip injuries, getting the appropriate medical attention is essential and following through with the right rehabilitation exercises can be crucial towards the athlete�s overall recovery and return to play.
For more information, please feel free to ask Dr. Jimenez or contact us at 915-850-0900�.
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