Common Causes for Hip Pain
The specific location of hip pain can give some insight to what the trouble might be. There are five areas of symptoms that I find are the most common when my patients report they are having hip pain: the sacro-iliac region, the trochanteric region, the groin region, the iliac crest, and the anterior hip.
Sacro-iliac Pain
This is the area of the body in the upper inner buttock that is close to the spine. Technically this is the pelvic region. Though, it doesn’t matter what we physicians call it, because most patients just complain about the hip and point to this area…which is good enough for me. Sacroiliac pain accounts for about
25% of all low back pain. The SI joint is composed of two big bones. This is the sacrum and the ilium. It is a large fibrous joint that has much less movement than your typical joint, but is very important for posture, gait, and weight bearing. The SI joint rocks forward and up or back and down.
Sometimes tight muscle groups or unlevel pelvis causes this joint to rock out of place one way or another and this causes excessive stress resulting in a deep achy or sometimes sharp pain that can travel up the back or down into the buttock. Correcting the joint position, rebalancing the muscle groups, and leveling the pelvis are the biggest points of care when I am treating an SI joint issue.
Trochanteric Pain: ITB and Bursitis
The side of the hip bone right where the femur meets the pelvis is another region of where lower extremity pain can originate. We call this the trochanteric region because the big bony area of the hip joint is called the trochanter. Lots of important structures lie in this area. The two biggest players are the tensor fasciae latae muscle which connects to the iliotibial band, and the trochanteric bursae. By far, these two structures are the most common sources of lateral hip pain. A tight tensor fasciae latae will pull on the iliotibial band causing tightening across the joint that leads to irritation and inflammation of the underlying trochanteric bursae. Typically, both problems occur together. In fact, the insurance companies code these two problems with the same code: Iliotibial band syndrome and trochanteric bursitis.
I find most people with this problem usually have a short leg and an unlevel pelvis. My treatment plan for this problem usually includes ultrasound/electro stimulation, manual release of the tensor fasciae latae and iliotibial band, and adjustments to correct the unlevel pelvis that includes the affected hip joint. There is typically spinal misalignment (normally a lumbar tilt) associated with this type of problem, so I usually end up treating the low back as well. Often the tension in the tensor fasciae latae and iliotibial band runs down the side of the leg and may even affect the outer knee. In this case, I may also need to address the knee joint.
Groin Pain: Pulled Groin and Osteoarthritis
The inner part of the hip joint is referred to as the groin…not that anybody needed me to explain that. It’s a common generator of lower extremity pain. Most all of us have “Pulled our groin” during some activity. This is typically a pulled adductor muscle. The problem affects younger patients who are active in sports, but can occur at any age.
There another culprit that I see regularly: Osteoarthritis. This is a type of arthritis that is due to the wear and tear of joints and typically affects joints that bear more weight. Osteoarthritis of the hip is almost always described as hip pain that is achy and sharp on the inside of the groin.
Iliac Crest Pain
The region at the top of the hip bone on the side of your body is the iliac crest.
We call it this because it is the upper most portion of the ilium. Just like the crest of a mountain. Attaching to the iliac crest is the quadratus lumborum muscle. If there is a misalignment in the pelvis or spine that causes tilting of the lumbar spine, this muscle becomes over active trying to fight the forces of gravity while in an upright position. While this is not really lower extremity pain, patient’s none-the-less call it their hips.
Eventually this can lead to pulling and irritation of the insertion of the quadratus lumborum right on the iliac crest. Typically I find that a patient tends to lean towards one side during lifting activities. This habit can lead to this sort of dysfunction. Stretching this muscle and aligning the spine and pelvis usually do the trick, but I always address proper lifting and bending habits to make sure it doesn’t come back.
Anterior (Frontal) Hip Pain
Anatomy
The hip flexor muscles include parts of the quadruceps (namely the rectus femoris), the iliopsoas complex, and the gracilis.
The iliacus muscle sits inside of the iliac bone and attaches to the upper part of the femur. The psoas muscle stretches from the upper part of the femur to the side of the lumbar spine. These two muscle’s fibers blend together and are therefore called the iliopsoas group. The rectus femoris is one of the four branches of the quadruceps muscle. It runs all the way from the base of the knee to the front of the ilium. It is the only part of the quadruceps to cross the hip joint. The graciliis is a small thin muscle that wraps around the leg starting from the front of the iliac bone down to the inside of the knee.
Mechanism of Injury
Strains in the hip flexor groups are fairly common in sports. Soccer players reaching for balls, runners overexerting themselves, contact sports that require rapid muscle recruitment. In fact, any action that forcibly brings the leg forward against resistance can cause these types of injury. It can happen with one big traumatic movement, or it can be a repetitive trauma, or a little of both. Tears in any of these muscles can create anterior hip pain.
Treatment
Hip-Flexor strains are addressed with P.R.I.C.E (protection, rest, ice, compression, elevation-when relevant) acutely within the first few days. Ultrasound helps to speed up healing. Rehab of the affected tissues is also important to regain functionality of the muscle/ligaments that have been damaged.
