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What to Do to Protect Your Hips

Posted on: 12/11/2008
More and more people are experiencing hip pain. Whether you are a sports athlete or an aging adult, protecting your hip joints is important in preventing hip pain. This is especially true for a condition called greater trochanteric pain syndrome (GTPS); also known as hip bursitis.

The greater trochanter is the large bump on the outside of the upper end of the femur (thigh bone). This bump is the point where the large buttock muscles that move the hip connect to the femur. The gluteus maximus is the largest of these muscles. It attaches lower down on the femur.

If you lie on a hard surface for very long, you will feel the effects on your greater trochanter. Where friction occurs between muscles, tendons, and bones, there is usually a structure called a bursa. A bursa is a thin sac of tissue that contains fluid to lubricate the area and reduce friction. The bursa is a normal structure. The body will even produce a bursa in response to friction.

Sometimes a bursa can become inflamed (swollen and irritated) because of too much friction or because of an injury to the bursa. An inflamed bursa can cause pain because movement makes the structures around the bursa rub against it.

Inflammation in the bursa between the tendon and the greater trochanter leads to greater trochanteric pain syndrome. This problem is common in older individuals. It may also occur in younger patients who are extremely active in exercises such as walking, running, or biking.

Friction can build in the bursa during walking if the long tendon on the side of the thigh is tight. It is unclear what causes this tightening of the tendon. The gluteus maximus attaches to this long tendon. As you walk, the gluteus maximus pulls this tendon over the greater trochanter with each step. When the tendon is tight, it rubs against the bursa.

The rubbing causes friction to build in the bursa, leading to irritation and inflammation. Patients with this problem report pain along the lateral (outside) of the hip, although the hip joint itself is not involved. The pain may radiate down the lateral aspect of the thigh. Friction can also start if the outer hip muscle (gluteus medius) is weak, if one leg is longer than the other, or if you run on slanted or uneven surfaces.

What can be done about this problem? Well, prevention is the first step. A proper relationship between the joint surfaces and muscle to joint interface is important. Good alignment means good joint integrity and normal range-of-motion. Leg alignment and symmetry is a big part of posture and alignment needed for normal biomechanics.

The foot is a good place to start when lining up the legs, hips, pelvis, and spine. Proper shoes that distribute the weight evenly over the foot and up into the legs is important. Athletes in training should especially pay attention to how many miles they put on a shoe and replace them often. New shoes should be purchased when the athlete has met the shoe manufacturer's limits on the lifespan of each pair of shoes.

Once the foot is in a stable, supported position of alignment, the entire kinetic chain (connection and force spread from foot to ankle to knee to thigh to hip) is supported. This is a large part of the prevention program. Core training is the next step. Strengthening the muscles of the spine, abdomen, and hips can help prevent hip pain.

If this type of conservative care does not help reduce or eliminate the patient's pain, then more direct medical intervention may be needed. The patient might benefit from nutritional supplements or even steroid injections into the hip. The injections contain a numbing agent and an antiinflammatory. Pain relief is possible in some patients with one or two shots to deposit the active ingredients into the largest hip bursa (located between the iliotibial band and the underlying gluteus medius muscle).

Physical therapy may be prescribed. The therapist will guide you in strengthening the appropriate muscles, including core training. Stretching the overlying soft tissue structures makes sense. Relieving tension in the structures around the greater trochanter reduces friction leading to the pain syndrome. The therapist has several other tools to help realign structures for pain relief.

If all of these techniques have been tried without success, surgery may be a final option. If there is a tendon tear, it is idébrided (cleaned up) and repaired. If the bursa is torn or frayed, the area can also be débrided. The surgeon can even shave the bone down around the greater trochanter to reduce pressure and friction causing painful symptoms. This procedure is called a reduction osteotomy.

During arthroscopic surgery, the surgeon can take a look at all the structures in and around the hip joint. Any loose fragments of cartilage, torn ligaments, or damaged cartilage can be removed or repaired. The surgeon can look and see if the bursa is inflamed or if tendons need débriding or repair.

A rehab program follows surgery. The program is much like what is done to prevent hip problems from occurring. Any muscle imbalances are addressed along with correction of any alignment issues. Core training and stretching of the muscles and iliotibial band along the outside of the thigh are key parts of the rehab program.

Patients who exercise regularly must be advised to follow a program of cross-training paying attention to shoe wear and surfaces they run or walk on. Older adults with signs of arthritis may want to try taking nutritional supplements such as glucosamine and chondroitin. There is some evidence that this approach can be helpful in restoring the joint surfaces.

Chris Dougherty, DO, and John J. Dougherty, DO. Managing and Preventing Hip Pathology in Trochanteric Pain Syndrome. In The Journal of Musculoskeletal Medicine. November 2008. Vol. 25. No. 11. Pp. 521-523.

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