Diagnosing Posterior Hip Pain in Athletes
Pain along the back of the hip can be a very complex and puzzling condition to figure out. It's a fairly rare problem and affects athletes involved in golf, dance, or soccer most often. This article was written to help physicians diagnose with accuracy the problem and the cause.
The best way to evaluate and diagnose patients with posterior hip pain is always with a systematic and logical approach. That means knowing the anatomy, possible causes of hip pain, how to classify the disorder, and ultimately, knowing how to treat the real underlying problem.
Because the patient's symptoms are often vague and hard to pinpoint, special tests and imaging studies aid in the diagnostic process. The physician must also keep in mind that pain along the back of the hip could be coming from elsewhere -- like the sacroiliac joint, low back, or knee. It could be from a muscle strain, hernia, degenerative disc disease, fracture, or even from a hip dislocation.
One thing we know for sure. Based on how the nerves to the skin, soft tissues, and muscles work, posterior hip pain is rarely coming from inside the hip joint. The most common source of this type of pain is from the muscles or bursae.
The bursae are tiny fluid-filled pads between layers of muscle or between muscle and bone. They cushion the force of load and strain on the area where they are located. But they can get pinched, compressed, and inflamed causing a well-known condition called bursitis.
How does the physician sort this all out? First, by taking a very complete patient history. What happened? How did it happen? What are the symptoms? When did the problem start and how long has it been bothering the athlete? What makes it better or worse? Through a series of questions, the examiner can often tell if there is anything more serious going on (e.g., fracture, tumor, systemic disorder).
Making sure there isn't some other medical condition behind the pain is important because hip pain can be coming from the gastrointestinal or reproductive systems. Treatment for those types of problems is very different from treatment for muscle or other soft tissue issues.
Testing begins with an assessment of posture, alignment, motion, strength, and flexibility. Most of the time, there are enough clues from the patient history and exam to make an accurate diagnosis.
But sometimes, it's necessary to take X-rays or order other imaging studies like MRIs, CT scans, ultrasound studies, or even arthrography. That last test involves injecting a dye into the joint and taking pictures to see if the dye seeps out of the joint into the bone or tissues around the joint.
Arthrography is really a test for problems inside the joint and the authors already made note of the fact that this is a rare source of posterior hip pain in the athletic population. With athletes, MRIs are the best way to evaluate the soft tissue structures around the hip.
The authors offer a discussion centered on six of the most likely causes of posterior hip pain in athletes. These include: 1) pain coming from the lumbar spine, 2) problems in the sacroiliac joint, 3) muscle pain, 4) piriformis syndrome, 5) hamstring rupture, and 6) femoroacetabular impingement.
Let's take a quick look at each one of these problems. Herniated discs that put pressure on the sciatic nerve are the most common cause of referred pain from the lumbar spine. Hip pain occurs in this instance because the L3 lumbar nerve root that can be pinched by a bulging or herniated disc also supplies sensation in the hip. A problem at L3 can produce symptoms in both places: the low back and the hip. The tip off is that with sciatica, there is back, buttock, and often leg pain.
Next is the sacroiliac joint. This is where the triangular-shaped sacrum is wedged between the two pelvic bones. Any problem with ligament strains, infection, fractures, or alignment in this area can cause what is felt as posterior hip pain. This problem can also send pain down the back of the leg, so further testing is often needed to tell the difference between pain coming from lumbar spine versus the sacroiliac joint.
Strain, overuse, or tear of any of the muscles that insert into the hip, low back, or sacroiliac area can cause posterior hip pain. Palpating for tenderness and testing hip muscle strength are the key diagnostic tests here. One muscle in particular to check for is the piriformis. The piriformis rotates the leg outward, a movement referred to as external rotation.
For some people, contraction of the piriformis muscle presses on the sciatic nerve. This is another problem that can refer pain down the leg. But it's one problem that doesn't show up well on X-rays, MRIs, CT scans, or other imaging studies. The physician may try treating the symptoms conservatively with antiinflammatories and physical therapy. If the symptoms don't go away, then it might be necessary to perform electrodiagnostic tests to confirm the diagnosis.
Ruptured hamstring muscles are much easier to diagnose. First of all, there is usually a history of trauma or specific injury the athlete can remember as the starting point of the problem. Muscle weakness is common with partial or complete tears. Surgery (as early as possible) is the most effective treatment for this problem.
And finally, there's femoroacetabular impingement. This refers to pinching of the soft tissues somewhere around the hip joint -- usually along the backside of the joint when the symptoms present in the buttock area. Certain hip motions will reproduce the pain and that's the main test for the problem. MRIs or CT scans are helpful in looking at the anatomy and seeing what might be contributing to the impingement problem.
Today's improved testing methods, updated technology, and better understanding of anatomy have made it possible to identify differences between and among these six possible causes of posterior hip pain. By performing a systematic examination and evaluation, the physician can complete the clinical workup and come to an accurate diagnosis.
Treatment decisions follow based on the cause or etiology of the problem. Most of the time, conservative (nonoperative) care works well to relieve pain, restore motion, and improve function. When athletes fail to improve with conservative care, then surgery may be considered as the next step. In a small number of problems (usually tendon or muscle ruptures), surgery is the first-line of treatment.
Rachel M. Frank, BS, et al. Posterior Hip Pain in an Athletic Population: Differential Diagnosis and Treatment Options. In Sports Health. May/June 2010. Vol. 2. No. 3. Pp. 237-246.